Kaiser Permanente - 2015 Individual Plan Membership ...info.kaiserpermanente.org/info_assets/child_health_plan/pdfs/... · Kaiser Foundation Health Plan, Inc. Northern and Southern

Kaiser Foundation Health Plan, Inc. Northern and Southern California Regions A nonprofit corporation

2015 Individual Plan Membership Agreement and Evidence of Coverage for Kaiser Permanente for Individuals and Families Kaiser Permanente - Platinum 90 HMO Pending regulatory approval

Member Service Contact Center 24 hours a day, seven days a week (except closed holidays, and closed after 5 p.m. the day after Thanksgiving, after 5 p.m. on Christmas Eve, and after 5 p.m. on New Year's Eve) 1-800-464-4000 toll free 1-800-777-1370 or 711 (toll free TTY for the hearing/speech impaired) kp.org

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Help in your language Interpreter services, including sign language, are available during all hours of operation at no cost to you. We can also provide you, your family, and friends with any special assistance needed to access our facilities and services. In addition, you may request health plan materials translated in your language, and may also request these materials in large text or in other formats to accommodate your needs. For more information, call our Member Service Contact Center 24 hours a day, seven days a week (except closed holidays, and closed after 5 p.m. the day after Thanksgiving, after 5 p.m. on Christmas Eve, and after 5 p.m. on New Year's Eve) at 1-800-464-4000 (TTY users call 1-800-777-1370 or 711). Ayuda en su idioma Se ofrecen servicios de intérprete sin costo alguno para usted durante todo el horario de atención, incluida la lengua de señas (sign language). También podemos ofrecerles a usted y a sus familiares y amigos todo tipo de ayuda especial que necesiten para tener acceso a nuestros centros y servicios. Además, puede solicitar que los materiales del plan de salud se traduzcan a su idioma, y que estos materiales sean con letra grande o en otros formatos que se acomoden a sus necesidades. Para obtener más información llame a la Central de Llamadas de Servicio a los Miembros las 24 horas del día, los siete días de la semana (excepto los días festivos y después de las 5 p. m. el día después de Thanksgiving [Día de Acción de Gracias], y las vísperas de Navidad y Año Nuevo) al 1-800-788-0616 (usuarios de TTY llamen al 1-800-777-1370 o al 711).

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VERSION_D ESCRIP TION MANUA L C1V4 REFR ESH P LANS P ER WMS F ID # 49641167 R LOVE

REASON_FOR_NEW _VERS ION RENEW ED

VER_REN_DAT E 01/01 /2015

TABLE OF CONTENTS

Health Plan Benefits and Coverage Matrix .................................................................................................................... 1 Introduction .................................................................................................................................................................. 3

Term of this Membership Agreement and Evidence of Coverage, Renewal, and Amendment ...................................... 3 About Kaiser Permanente .......................................................................................................................................... 4

Definitions .................................................................................................................................................................... 4 Premiums, Eligibility, and Enrollment ........................................................................................................................... 9

Premiums .................................................................................................................................................................. 9 Who Is Eligible ........................................................................................................................................................10 How to Enroll and When Coverage Begins ...............................................................................................................11

How to Obtain Services ................................................................................................................................................13 Routine Care ............................................................................................................................................................13 Urgent Care .............................................................................................................................................................13 Not Sure What Kind of Care You Need?...................................................................................................................14 Your Personal Plan Physician ...................................................................................................................................14 Getting a Referral .....................................................................................................................................................14 Second Opinions ......................................................................................................................................................15 Interactive Video Visits ............................................................................................................................................16 Contracts with Plan Providers ...................................................................................................................................16 Visiting Other Regions .............................................................................................................................................17 Your ID Card ...........................................................................................................................................................17 Getting Assistance....................................................................................................................................................17

Plan Facilities ..............................................................................................................................................................18 Emergency Services and Urgent Care ...........................................................................................................................18

Emergency Services .................................................................................................................................................18 Urgent Care .............................................................................................................................................................19 Payment and Reimbursement ...................................................................................................................................20

Benefits and Your Cost Share .......................................................................................................................................20 Your Cost Share .......................................................................................................................................................21 Preventive Care Services ..........................................................................................................................................23 Outpatient Care ........................................................................................................................................................23 Hospital Inpatient Care .............................................................................................................................................25 Ambulance Services .................................................................................................................................................25 Bariatric Surgery ......................................................................................................................................................26 Behavioral Health Treatment for Pervasive Developmental Disorder or Autism ........................................................26 Chemical Dependency Services ................................................................................................................................28 Dental and Orthodontic Services...............................................................................................................................28 Dialysis Care............................................................................................................................................................29 Durable Medical Equipment for Home Use...............................................................................................................30 Family Planning Services .........................................................................................................................................31 Health Education ......................................................................................................................................................32 Hearing Services ......................................................................................................................................................32 Home Health Care ....................................................................................................................................................32 Hospice Care............................................................................................................................................................33 Infertility Services ....................................................................................................................................................34 Mental Health Services.............................................................................................................................................34 Ostomy and Urological Supplies...............................................................................................................................35 Outpatient Imaging, Laboratory, and Special Procedures...........................................................................................36 Outpatient Prescription Drugs, Supplies, and Supplements ........................................................................................36

Prosthetic and Orthotic Devices ................................................................................................................................40 Reconstructive Surgery ............................................................................................................................................41 Rehabilitative and Habilitative Services ....................................................................................................................42 Services in Connection with a Clinical Trial .............................................................................................................43 Skilled Nursing Facility Care ....................................................................................................................................43 Transplant Services ..................................................................................................................................................44 Vision Services ........................................................................................................................................................44

Exclusions, Limitations, Coordination of Benefits, and Reductions ...............................................................................46 Exclusions ...............................................................................................................................................................46 Limitations ...............................................................................................................................................................49 Coordination of Benefits ..........................................................................................................................................49 Reductions ...............................................................................................................................................................49

Post-Service Claims and Appeals .................................................................................................................................51 Who May File ..........................................................................................................................................................51 Supporting Documents .............................................................................................................................................52 Initial Claims ...........................................................................................................................................................52 Appeals ....................................................................................................................................................................53 External Review .......................................................................................................................................................54 Additional Review ...................................................................................................................................................54

Dispute Resolution .......................................................................................................................................................54 Grievances ...............................................................................................................................................................54 Department of Managed Health Care Complaints......................................................................................................57 Independent Medical Review (IMR) .........................................................................................................................57 Additional Review ...................................................................................................................................................58 Binding Arbitration ..................................................................................................................................................58

Termination of Membership .........................................................................................................................................60 How You May Terminate Your Membership ............................................................................................................60 Termination Due to Loss of Eligibility ......................................................................................................................61 Termination for Cause ..............................................................................................................................................61 Termination for Nonpayment of Premiums ...............................................................................................................61 Termination for Discontinuance of a Product or all Products .....................................................................................62 Payments after Termination ......................................................................................................................................63 Appealing Membership Termination.........................................................................................................................63 State Review of Membership Termination ................................................................................................................63

Miscellaneous Provisions .............................................................................................................................................63 Helpful Information .....................................................................................................................................................65

Your Guidebook to Kaiser Permanente Services (Your Guidebook) ..........................................................................65 Online Tools and Resources .....................................................................................................................................65 How to Reach Us .....................................................................................................................................................65 Payment Responsibility ............................................................................................................................................66

2015 Pediatric Dental Services Amendment .................................................................................................................68 Introduction .............................................................................................................................................................69 Definitions ...............................................................................................................................................................69 How to Obtain Pediatric Dental Services ..................................................................................................................70 Benefits, Limitations and Exclusions ........................................................................................................................71 Emergency Pediatric Dental Services ........................................................................................................................71 Specialist Services....................................................................................................................................................71 Claims for Reimbursement .......................................................................................................................................72 Cost Share and Other Charges ..................................................................................................................................72 Second Opinion........................................................................................................................................................72 Special Needs...........................................................................................................................................................72

Facility Accessibility ................................................................................................................................................73 Provider Compensation ............................................................................................................................................73 Processing Policies ...................................................................................................................................................73 Enrollee Complaint Procedure ..................................................................................................................................73 SCHEDULE A - Description of Benefits and Cost Share for Pediatric Benefits (Under Age 19) ................................75 SCHEDULE B - Limitations and Exclusions of Benefits...........................................................................................86 SCHEDULE C - Information Concerning Benefits Under The DeltaCare USA Program ...........................................91

Health Plan Benefits and Coverage Matrix THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Accumulation Period The Accumulation Period for this plan is 1/1/15 through 12/31/15 (calendar year).

Out-of-Pocket Maximum You will not pay any more Cost Share during the calendar year if the Copayments and Coinsurance you pay add up to one of the following amounts:

For self-only enrollment (a Family of one Member) .......................... $4,000 per calendar year For any one Member in a Family of two or more Members ................ $4,000 per calendar year For an entire Family of two or more Members ................................... $8,000 per calendar year

Plan Deductible None

Lifetime Maximum None

Professional Services (Plan Provider office visits) You Pay Most Primary Care Visits for evaluations and treatment .......................... $20 per visit Most Specialty Care Visits for consultations, evaluations, and treatment .. $40 per visit Routine physical maintenance exams, including well-woman exams ........ No charge Well-child preventive exams (through age 23 months) ............................ No charge Family planning counseling and consultations ......................................... No charge Scheduled prenatal care exams ................................................................ No charge Routine eye exams with a Plan Optometrist for Members under age 19 .... No charge Hearing exams ........................................................................................ No charge Urgent care consultations, evaluations, and treatment .............................. $20 per visit Most physical, occupational, and speech therapy ..................................... $20 per visit

Outpatient Services You Pay Outpatient surgery and certain other outpatient procedures ...................... $250 per procedure Allergy injections (including allergy serum) ............................................ $5 per visit Most immunizations (including the vaccine) .......................................... No charge Most X-rays .......................................................................................... $40 per encounter Most laboratory tests .............................................................................. $20 per encounter Preventive X-rays, screenings, and laboratory tests as described in the "Benefits and Your Cost Share" section ................................................ No charge

MRI, most CT, and PET scans ................................................................ $150 per procedure Covered individual health education counseling ..................................... No charge Covered health education programs ........................................................ No charge

Hospitalization Services You Pay Room and board, surgery, anesthesia, X-rays, laboratory tests, and drugs $250 per day up to a maximum of $1,250 per

admission

Emergency Health Coverage You Pay Emergency Department visits ................................................................. $150 per visit Note: This Cost Share does not apply if admitted directly to the hospital as an inpatient for covered Services (see "Hospitalization Services" for inpatient Cost Share).

Ambulance Services You Pay Ambulance Services ............................................................................... $150 per trip

Kaiser Permanente – Platinum 90 HMO Date: June 15, 2014 Page 1

Prescription Drug Coverage You Pay Covered outpatient items in accord with our drug formulary guidelines:

Most generic items at a Plan Pharmacy ............................................. $5 for up to a 30-day supply Most generic refills through our mail-order service ............................ $10 for up to a 100-day supply Most brand-name items at a Plan Pharmacy ....................................... $15 for up to a 30-day supply Most brand-name refills through our mail-order service ..................... $30 for up to a 100-day supply Most specialty items at a Plan Pharmacy ............................................ 10% Coinsurance for up to a 100-day supply

Durable Medical Equipment (DME) You Pay DME items that are essential health benefits in accord with our DME formulary guidelines ............................................................................ 10% Coinsurance

Mental Health Services You Pay Inpatient psychiatric hospitalization ........................................................ $250 per day up to a maximum of $1,250 per

admission Individual outpatient mental health evaluation and treatment ................... $20 per visit Group outpatient mental health treatment ................................................ $10 per visit

Chemical Dependency Services You Pay Inpatient detoxification ........................................................................... $250 per day up to a maximum of $1,250 per

admission Individual outpatient chemical dependency evaluation and treatment ....... $20 per visit Group outpatient chemical dependency treatment .................................... $5 per visit

Home Health Services You Pay Home health care (up to 100 visits per calendar year) .............................. No charge

Other You Pay Eyeglasses or contact lenses purchased at Plan Medical Offices or Plan Optical Sales Offices for Members under age 19:

Eyeglass frame from selected styles per calendar year ....................... No charge Regular eyeglass lenses per calendar year .......................................... No charge Standard contact lenses per calendar year .......................................... No charge

Skilled Nursing Facility care (up to 100 days per benefit period) ............ $150 per day up to a maximum of $750 per admission

Ostomy and urological supplies .............................................................. No charge Prosthetic and orthotic devices that are essential health benefits ............... No charge Hospice care .......................................................................................... No charge This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Cost Share, out-of-pocket maximums, exclusions, or limitations, nor does it list all benefits and Cost Share amounts. For a complete explanation, please refer to the "Benefits and Your Cost Share" and "Exclusions, Limitations, Coordination of Benefits, and Reductions" sections.


Introduction

This Membership Agreement and Evidence of Coverage describes the health care coverage of "Kaiser Permanente - Platinum 90 HMO." This Membership Agreement and Evidence of Coverage, the Rate Sheet which is incorporated into this Membership Agreement and Evidence of Coverage by reference, and any amendments, constitute the legally binding contract between Health Plan (Kaiser Foundation Health Plan, Inc.) and the Subscriber.

For benefits provided under any other Health Plan program, refer to that plan's evidence of coverage.

In this Membership Agreement and Evidence of Coverage, Health Plan is sometimes referred to as "we" or "us." Members are sometimes referred to as "you." Some capitalized terms have special meaning in this Membership Agreement and Evidence of Coverage; please see the "Definitions" section for terms you should know.

When you join Kaiser Permanente, you are enrolling in one of two Health Plan Regions in California (either our Northern California Region or Southern California Region), which we call your "Home Region." The Service Area of each Region is described in the "Definitions" section of this Membership Agreement and Evidence of Coverage. The coverage information in this Membership Agreement and Evidence of Coverage applies when you obtain care in your Home Region. When you visit the other California Region, you may receive care as described in "Visiting Other Regions" in the "How to Obtain Services" section.

PLEASE READ THE FOLLOWING INFORMATION SO THAT YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS YOU MAY GET HEALTH CARE.

It is important to familiarize yourself with your coverage by reading this Membership Agreement and Evidence of Coverage completely, so that you can take full advantage of your Health Plan benefits. Also, if you have special health care needs, please carefully read the sections that apply to you.

Note: The Health Plan Benefits and Coverage Matrix is located in the front of this Membership Agreement and Evidence of Coverage.

Term of this Membership Agreement and Evidence of Coverage, Renewal, and Amendment Term of this Membership Agreement and Evidence of Coverage This Membership Agreement and Evidence of Coverage becomes effective on the membership effective date in the Subscriber's acceptance letter and will remain in effect until one of the following occurs: • The Membership Agreement and Evidence of

Coverage is amended as described under "Amendment of Membership Agreement and Evidence of Coverage" in this "Introduction" section

• There are no longer any Members in your Family who are covered under this Membership Agreement and Evidence of Coverage

Note: Your membership may terminate even if this Membership Agreement and Evidence of Coverage remains in effect for other covered Members of your Family. The "Termination of Membership" section explains how membership may terminate.

Renewal If you comply with all of the terms of this Membership Agreement and Evidence of Coverage, we will automatically renew this Membership Agreement and Evidence of Coverage each year, effective January 1. Terms of the Membership Agreement and Evidence of Coverage will remain the same when we renew it unless we have amended the Membership Agreement and Evidence of Coverage as described under "Amendment of Membership Agreement and Evidence of Coverage" in this "Term of this Membership Agreement and Evidence of Coverage, Renewal, and Amendment" section.

Amendment of Membership Agreement and Evidence of Coverage In accord with "Notices" in the "Miscellaneous Provisions" section, we may amend this Membership Agreement and Evidence of Coverage (including Premiums and benefits) at any time by sending written notice to the Subscriber at least 60 days before the effective date of the amendment. The amendment may become effective earlier than the end of the period for which you have already paid your Premiums, and it may require you to pay additional Premiums for that period. All amendments are deemed accepted by the Subscriber unless the Subscriber gives us written notice of non-acceptance within 30 days of the date of the notice, in which case this Membership Agreement and Evidence of Coverage terminates the day before the effective date of the amendment.


If we notified the Subscriber that we have not received all necessary governmental approvals related to this Membership Agreement and Evidence of Coverage, we may amend this Membership Agreement and Evidence of Coverage by giving written notice to the Subscriber after receiving all necessary governmental approval, in accord with "Notices" in the "Miscellaneous Provisions" section. Any such government-approved provisions go into effect on January 1, 2015 (unless the government requires a later effective date).

About Kaiser Permanente Kaiser Permanente provides Services directly to our Members through an integrated medical care program. Health Plan, Plan Hospitals, and the Medical Group work together to provide our Members with quality care. Our medical care program gives you access to all of the covered Services you may need, such as routine care with your own personal Plan Physician, hospital care, laboratory and pharmacy Services, Emergency Services, Urgent Care, and other benefits described in the "Benefits and Your Cost Share" section. Plus, our health education programs offer you great ways to protect and improve your health.

We provide covered Services to Members using Plan Providers located in your Home Region Service Area, which is described in the "Definitions" section. You must receive all covered care from Plan Providers inside your Home Region Service Area, except as described in the sections listed below for the following Services: • Authorized referrals as described under "Getting a

Referral" in the "How to Obtain Services" section • Emergency ambulance Services as described under

"Ambulance Services" in the "Benefits and Your Cost Share" section

• Emergency Services, Post-Stabilization Care, and Out-of-Area Urgent Care as described in the "Emergency Services and Urgent Care" section

• Hospice care as described under "Hospice Care" in the "Benefits and Your Cost Share" section

Definitions

Some terms have special meaning in this Membership Agreement and Evidence of Coverage. When we use a term with special meaning in only one section of this Membership Agreement and Evidence of Coverage, we define it in that section. The terms in this "Definitions" section have special meaning when capitalized and used

in any section of this Membership Agreement and Evidence of Coverage.

Allowance: A specified credit amount that you can use toward the purchase price of an item. If the price of the item(s) you select exceeds the Allowance, you will pay the amount in excess of the Allowance (and that payment will not apply toward any deductible or out-of-pocket maximum).

Charges: "Charges" means the following:

• For Services provided by the Medical Group or Kaiser Foundation Hospitals, the charges in Health Plan's schedule of Medical Group and Kaiser Foundation Hospitals charges for Services provided to Members

• For Services for which a provider (other than the Medical Group or Kaiser Foundation Hospitals) is compensated on a capitation basis, the charges in the schedule of charges that Kaiser Permanente negotiates with the capitated provider

• For items obtained at a pharmacy owned and operated by Kaiser Permanente, the amount the pharmacy would charge a Member for the item if a Member's benefit plan did not cover the item (this amount is an estimate of: the cost of acquiring, storing, and dispensing drugs, the direct and indirect costs of providing Kaiser Permanente pharmacy Services to Members, and the pharmacy program's contribution to the net revenue requirements of Health Plan)

• For all other Services, the payments that Kaiser Permanente makes for the Services or, if Kaiser Permanente subtracts your Cost Share from its payment, the amount Kaiser Permanente would have paid if it did not subtract your Cost Share

Coinsurance: A percentage of Charges that you must pay when you receive a covered Service under this Membership Agreement and Evidence of Coverage.

Copayment: A specific dollar amount that you must pay when you receive a covered Service under this Membership Agreement and Evidence of Coverage. Note: The dollar amount of the Copayment can be $0 (no charge).

Cost Share: The amount you are required to pay for covered Services. For example, your Cost Share may be a Copayment or Coinsurance. If your coverage includes a Plan Deductible and you receive Services that are subject to the Plan Deductible, your Cost Share will be Charges if you have not met the Plan Deductible.

Dependent: A Member who meets the eligibility requirements as a Dependent (for Dependent eligibility requirements, see "Who Is Eligible" in the "Premiums, Eligibility, and Enrollment" section).


Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a reasonable person would have believed that the absence of immediate medical attention would result in any of the following: • Placing the person's health (or, with respect to a

pregnant woman, the health of the woman or her unborn child) in serious jeopardy

• Serious impairment to bodily functions

• Serious dysfunction of any bodily organ or part

A mental health condition is an Emergency Medical Condition when it meets the requirements of the paragraph above, or when the condition manifests itself by acute symptoms of sufficient severity such that either of the following is true: • The person is an immediate danger to himself or

herself or to others • The person is immediately unable to provide for, or

use, food, shelter, or clothing, due to the mental disorder

Emergency Services: All of the following with respect to an Emergency Medical Condition: • A medical screening exam that is within the

capability of the emergency department of a hospital, including ancillary services (such as imaging and laboratory Services) routinely available to the emergency department to evaluate the Emergency Medical Condition

• Within the capabilities of the staff and facilities available at the hospital, Medically Necessary examination and treatment required to Stabilize the patient (once your condition is Stabilized, Services you receive are Post Stabilization Care and not Emergency Services)

Family: A Subscriber and all of his or her Dependents.

Health Plan: Kaiser Foundation Health Plan, Inc., a California nonprofit corporation. This Membership Agreement and Evidence of Coverage sometimes refers to Health Plan as "we" or "us."

Home Region: The Region where you enrolled (either the Northern California Region or the Southern California Region).

Kaiser Permanente: Kaiser Foundation Hospitals (a California nonprofit corporation), Health Plan, and the Medical Group.

Medical Group: For Northern California Region Members, The Permanente Medical Group, Inc., a for-profit professional corporation, and for Southern California Region Members, the Southern California

Permanente Medical Group, a for-profit professional partnership.

Medically Necessary: A Service is Medically Necessary if it is medically appropriate and required to prevent, diagnose, or treat your condition or clinical symptoms in accord with generally accepted professional standards of practice that are consistent with a standard of care in the medical community.

Medicare: The federal health insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and people with end-stage renal disease (generally those with permanent kidney failure who need dialysis or a kidney transplant).

Member: A person who is eligible and enrolled under this Membership Agreement and Evidence of Coverage, and for whom we have received applicable Premiums. This Membership Agreement and Evidence of Coverage sometimes refers to a Member as "you."

Membership Agreement and Evidence of Coverage: This Membership Agreement and Evidence of Coverage document, which describes your Health Plan coverage. This Membership Agreement and Evidence of Coverage and the Rate Sheet which is incorporated into this Membership Agreement and Evidence of Coverage by reference, and any amendments, constitute the legally binding contract between Health Plan and the Subscriber.

Non–Plan Hospital: A hospital other than a Plan Hospital.

Non–Plan Physician: A physician other than a Plan Physician.

Non–Plan Provider: A provider other than a Plan Provider.

Out-of-Area Urgent Care: Medically Necessary Services to prevent serious deterioration of your (or your unborn child's) health resulting from an unforeseen illness, unforeseen injury, or unforeseen complication of an existing condition (including pregnancy) if all of the following are true:

• You are temporarily outside your Home Region Service Area

• A reasonable person would have believed that your (or your unborn child's) health would seriously deteriorate if you delayed treatment until you returned to your Home Region Service Area

Plan Deductible: The amount you must pay in the calendar year for certain Services before we will cover those Services at the applicable Copayment or Coinsurance in that calendar year. Please refer to the "Benefits and Your Cost Share" section to learn whether your coverage includes a Plan Deductible, the Services


that are subject to the Plan Deductible, and the Plan Deductible amount.

Plan Facility: Any facility listed on our website at kp.org/facilities for your Home Region Service Area, except that Plan Facilities are subject to change at any time without notice. For the current locations of Plan Facilities, please call our Member Service Contact Center.

Plan Hospital: Any hospital listed on our website at kp.org/facilities for your Home Region Service Area, except that Plan Hospitals are subject to change at any time without notice. For the current locations of Plan Hospitals, please call our Member Service Contact Center.

Plan Medical Office: Any medical office listed on our website at kp.org/facilities for your Home Region Service Area, except that Plan Medical Offices are subject to change at any time without notice. For the current locations of Plan Medical Offices, please call our Member Service Contact Center.

Plan Optical Sales Office: An optical sales office owned and operated by Kaiser Permanente or another optical sales office that we designate. Please refer to Your Guidebook for a list of Plan Optical Sales Offices in your area, except that Plan Optical Sales Offices are subject to change at any time without notice. For the current locations of Plan Optical Sales Offices, please call our Member Service Contact Center.

Plan Optometrist: An optometrist who is a Plan Provider.

Plan Pharmacy: A pharmacy owned and operated by Kaiser Permanente or another pharmacy that we designate. Please refer to Your Guidebook for a list of Plan Pharmacies in your area, except that Plan Pharmacies are subject to change at any time without notice. For the current locations of Plan Pharmacies, please call our Member Service Contact Center.

Plan Physician: Any licensed physician who is a partner or employee of the Medical Group, or any licensed physician who contracts to provide Services to Members (but not including physicians who contract only to provide referral Services).

Plan Provider: A Plan Hospital, a Plan Physician, the Medical Group, a Plan Pharmacy, or any other health care provider that we designate as a Plan Provider.

Plan Skilled Nursing Facility: A Skilled Nursing Facility approved by Health Plan.

Post-Stabilization Care: Medically Necessary Services related to your Emergency Medical Condition that you receive in a hospital (including the Emergency

Department) after your treating physician determines that this condition is Stabilized.

Premiums: Periodic membership charges paid by or on behalf of each Member. Premiums are in addition to any Cost Share.

Preventive Care Services: Services that do one or more of the following: • Protect against disease, such as in the use of

immunizations • Promote health, such as counseling on tobacco use

• Detect disease in its earliest stages before noticeable symptoms develop, such as screening for breast cancer

Primary Care Physicians: Generalists in internal medicine, pediatrics, and family practice, and specialists in obstetrics/gynecology whom the Medical Group designates as Primary Care Physicians. Please refer to our website at kp.org for a directory of Primary Care Physicians, except that the directory is subject to change without notice. For the current list of physicians that are available as Primary Care Physicians, please call the personal physician selection department at the phone number listed in Your Guidebook.

Primary Care Visits: Evaluations and treatment provided by Primary Care Physicians and primary care Plan Providers who are not physicians (such as nurse practitioners).

Rate Sheet: The document that lists premiums for Kaiser Permanente for Individuals and Families plans. The Premium for your coverage under this Membership Agreement and Evidence of Coverage is listed in the Rate Sheet included with the Subscriber's acceptance letter, unless the Rate Sheet has been amended as described under "Amendment of Membership Agreement and Evidence of Coverage" under "Term of this Membership Agreement and Evidence of Coverage, Renewal, and Amendment" in the "Introduction" section.

Region: A Kaiser Foundation Health Plan organization or allied plan that conducts a direct-service health care program. Regions may change on January 1 of each year and are currently the District of Columbia and parts of Northern California, Southern California, Colorado, Georgia, Hawaii, Idaho, Maryland, Oregon, Virginia, and Washington. For the current list of Region locations, please visit our website at kp.org or call our Member Service Contact Center.

Service Area: Health Plan has two Regions in California. As a Member, you are enrolled in one of the two Regions (either our Northern California Region or Southern California Region), called your Home Region.


This Membership Agreement and Evidence of Coverage describes the coverage for both California Regions.

Northern California Region Service Area

The ZIP codes below for each county are in our Northern California Service Area:

• All ZIP codes in Alameda County are inside our Northern California Service Area: 94501–02, 94514, 94536–46, 94550–52, 94555, 94557, 94560, 94566, 94568, 94577–80, 94586–88, 94601–15, 94617–21, 94622–24, 94649, 94659–62, 94666, 94701–10, 94712, 94720, 95377, 95391

• The following ZIP codes in Amador County are inside our Northern California Service Area: 95640, 95669

• All ZIP codes in Contra Costa County are inside our Northern California Service Area: 94505–07, 94509, 94511, 94513–14, 94516–31, 94547–49, 94551, 94553, 94556, 94561, 94563–65, 94569–70, 94572, 94575, 94582–83, 94595–98, 94706–08, 94801–08, 94820, 94850

• The following ZIP codes in El Dorado County are inside our Northern California Service Area: 95613–14, 95619, 95623, 95633–35, 95651, 95664, 95667, 95672, 95682, 95762

• The following ZIP codes in Fresno County are inside our Northern California Service Area: 93242, 93602, 93606–07, 93609, 93611–13, 93616, 93618–19, 93624–27, 93630–31, 93646, 93648–52, 93654, 93656–57, 93660, 93662, 93667–68, 93675, 93701–12, 93714–18, 93720–30, 93737, 93740–41, 93744–45, 93747, 93750, 93755, 93760–61, 93764–65, 93771–79, 93786, 93790–94, 93844, 93888

• The following ZIP codes in Kings County are inside our Northern California Service Area: 93230, 93232, 93242, 93631, 93656

• The following ZIP codes in Madera County are inside our Northern California Service Area: 93601–02, 93604, 93614, 93623, 93626, 93636–39, 93643–45, 93653, 93669, 93720

• All ZIP codes in Marin County are inside our Northern California Service Area: 94901, 94903–04, 94912–15, 94920, 94924–25, 94929–30, 94933, 94937–42, 94945–50, 94956–57, 94960, 94963–66, 94970–71, 94973–74, 94976–79

• The following ZIP codes in Mariposa County are inside our Northern California Service Area: 93601, 93623, 93653

• The following ZIP codes in Napa County are inside our Northern California Service Area: 94503, 94508,

94515, 94558–59, 94562, 94567, 94573–74, 94576, 94581, 94589–90, 94599, 95476

• The following ZIP codes in Placer County are inside our Northern California Service Area: 95602–04, 95626, 95648, 95650, 95658, 95661, 95663, 95668, 95677–78, 95681, 95692, 95703, 95722, 95736, 95746–47, 95765

• All ZIP codes in Sacramento County are inside our Northern California Service Area: 94203–09, 94211, 94229–30, 94232, 94234–37, 94239–40, 94244, 94246–50, 94252, 94254, 94256–59, 94261–63, 94267–69, 94271, 94273–74, 94277–80, 94282–91, 94293–98, 94571, 95608–11, 95615, 95621, 95624, 95626, 95628, 95630, 95632, 95638–41, 95652, 95655, 95660, 95662, 95670–71, 95673, 95678, 95680, 95683, 95690, 95693, 95741–42, 95757–59, 95763, 95811–38, 95840–43, 95851–53, 95860, 95864–67, 95894, 95899

• All ZIP codes in San Francisco County are inside our Northern California Service Area: 94102–05, 94107–12, 94114–27, 94129–34, 94137, 94139–47, 94151, 94158–61, 94163–64, 94172, 94177, 94188

• All ZIP codes in San Joaquin County are inside our Northern California Service Area: 94514, 95201–13, 95215, 95219–20, 95227, 95230–31, 95234, 95236–37, 95240–42, 95253, 95258, 95267, 95269, 95296–97, 95304, 95320, 95330, 95336–37, 95361, 95366, 95376–78, 95385, 95391, 95632, 95686, 95690

• All ZIP codes in San Mateo County are inside our Northern California Service Area: 94002, 94005, 94010–11, 94014–21, 94025–28, 94030, 94037–38, 94044, 94060–66, 94070, 94074, 94080, 94083, 94128, 94303, 94401–04, 94497

• The following ZIP codes in Santa Clara County are inside our Northern California Service Area: 94022–24, 94035, 94039–43, 94085–89, 94301–06, 94309, 94550, 95002, 95008–09, 95011, 95013–15, 95020–21, 95026, 95030–33, 95035–38, 95042, 95044, 95046, 95050–56, 95070–71, 95076, 95101, 95103, 95106, 95108–13, 95115–36, 95138–41, 95148, 95150–61, 95164, 95170, 95172–73, 95190–94, 95196

• All ZIP codes in Solano County are inside our Northern California Service Area: 94510, 94512, 94533–35, 94571, 94585, 94589–92, 95616, 95620, 95625, 95687–88, 95690, 95694, 95696

• The following ZIP codes in Sonoma County are inside our Northern California Service Area: 94515, 94922–23, 94926–28, 94931, 94951–55, 94972, 94975, 94999, 95401–07, 95409, 95416, 95419, 95421, 95425, 95430–31, 95433, 95436, 95439, 95441–42, 95444, 95446, 95448, 95450, 95452, 95462, 95465, 95471–73, 95476, 95486–87, 95492


• All ZIP codes in Stanislaus County are inside our Northern California Service Area: 95230, 95304, 95307, 95313, 95316, 95319, 95322–23, 95326, 95328–29, 95350–58, 95360–61, 95363, 95367–68, 95380–82, 95385–87, 95397

• The following ZIP codes in Sutter County are inside our Northern California Service Area: 95626, 95645, 95648, 95659, 95668, 95674, 95676, 95692, 95836–37

• The following ZIP codes in Tulare County are inside our Northern California Service Area: 93238, 93261, 93618, 93631, 93646, 93654, 93666, 93673

• The following ZIP codes in Yolo County are inside our Northern California Service Area: 95605, 95607, 95612, 95616–18, 95645, 95691, 95694–95, 95697–98, 95776, 95798–99

• The following ZIP codes in Yuba County are inside our Northern California Service Area: 95692, 95903, 95961

Southern California Region Service Area

The ZIP codes below for each county are in our Southern California Service Area:

• The following ZIP codes in Imperial County are inside our Southern California Service Area: 92274–75

• The following ZIP codes in Kern County are inside our Southern California Service Area: 93203, 93205–06, 93215–16, 93220, 93222, 93224–26, 93238, 93240–41, 93243, 93249–52, 93263, 93268, 93276, 93280, 93285, 93287, 93301–09, 93311–14, 93380, 93383–90, 93501–02, 93504–05, 93518–19, 93531, 93536, 93560–61, 93581

• The following ZIP codes in Los Angeles County are inside our Southern California Service Area: 90001–84, 90086–91, 90093–96, 90099, 90189, 90201–02, 90209–13, 90220–24, 90230–33, 90239–42, 90245, 90247–51, 90254–55, 90260–67, 90270, 90272, 90274–75, 90277–78, 90280, 90290–96, 90301–12, 90401–11, 90501–10, 90601–10, 90623, 90630–31, 90637–40, 90650–52, 90660–62, 90670–71, 90701–03, 90706–07, 90710–17, 90723, 90731–34, 90744–49, 90755, 90801–10, 90813–15, 90822, 90831–35, 90840, 90842, 90844, 90846–48, 90853, 90895, 90899, 91001, 91003, 91006–12, 91016–17, 91020–21, 91023–25, 91030–31, 91040–43, 91046, 91066, 91077, 91101–10, 91114–18, 91121, 91123–26, 91129, 91182, 91184–85, 91188–89, 91199, 91201–10, 91214, 91221–22, 91224–26, 91301–11, 91313, 91316, 91321–22, 91324–31, 91333–35, 91337, 91340–46, 91350–57, 91361–62, 91364–65, 91367, 91371–72, 91376, 91380–87, 91390, 91392–96, 91401–13, 91416, 91423, 91426, 91436, 91470,

91482, 91495–96, 91499, 91501–08, 91510, 91521–23, 91526, 91601–12, 91614–18, 91702, 91706, 91709, 91711, 91714–16, 91722–24, 91731–35, 91740–41, 91744–50, 91754–56, 91765–73, 91775–76, 91778, 91780, 91788–93, 91801–04, 91896, 91899, 93243, 93510, 93532, 93534–36, 93539, 93543–44, 93550–53, 93560, 93563, 93584, 93586, 93590–91, 93599

• All ZIP codes in Orange County are inside our Southern California Service Area: 90620–24, 90630–33, 90638, 90680, 90720–21, 90740, 90742–43, 92602–07, 92609–10, 92612, 92614–20, 92623–30, 92637, 92646–63, 92672–79, 92683–85, 92688, 92690–94, 92697–98, 92701–08, 92711–12, 92728, 92735, 92780–82, 92799, 92801–09, 92811–12, 92814–17, 92821–23, 92825, 92831–38, 92840–46, 92850, 92856–57, 92859, 92861–71, 92885–87, 92899

• The following ZIP codes in Riverside County are inside our Southern California Service Area: 91752, 92201–03, 92210–11, 92220, 92223, 92230, 92234–36, 92240–41, 92247–48, 92253–55, 92258, 92260–64, 92270, 92274, 92276, 92282, 92320, 92324, 92373, 92399, 92501–09, 92513–19, 92521–22, 92530–32, 92543–46, 92548, 92551–57, 92562–64, 92567, 92570–72, 92581–87, 92589–93, 92595–96, 92599, 92860, 92877–83

• The following ZIP codes in San Bernardino County are inside our Southern California Service Area: 91701, 91708–10, 91729–30, 91737, 91739, 91743, 91758–59, 91761–64, 91766, 91784–86, 91792, 92252, 92256, 92268, 92277–78, 92284–86, 92305, 92307–08, 92313–18, 92321–22, 92324–25, 92329, 92331, 92333–37, 92339–41, 92344–46, 92350, 92352, 92354, 92357–59, 92369, 92371–78, 92382, 92385–86, 92391–95, 92397, 92399, 92401–08, 92410–11, 92413, 92415, 92418, 92423, 92427, 92880

• The following ZIP codes in San Diego County are inside our Southern California Service Area: 91901–03, 91908–17, 91921, 91931–33, 91935, 91941–46, 91950–51, 91962–63, 91976–80, 91987, 92003, 92007–11, 92013–14, 92018–30, 92033, 92037–40, 92046, 92049, 92051–52, 92054–61, 92064–65, 92067–69, 92071–72, 92074–75, 92078–79, 92081–86, 92088, 92091–93, 92096, 92101–24, 92126–32, 92134–40, 92142–43, 92145, 92147, 92149–50, 92152–55, 92158–61, 92163, 92165–79, 92182, 92186–87, 92190–93, 92195–99

• The following ZIP codes in Ventura County are inside our Southern California Service Area: 90265, 91304, 91307, 91311, 91319–20, 91358–62, 91377, 93001–07, 93009–12, 93015–16, 93020–22, 93030–36, 93040–44, 93060–66, 93094, 93099, 93252


For each ZIP code listed for a county, your Home Region Service Area includes only the part of that ZIP code that is in that county. When a ZIP code spans more than one county, the part of that ZIP code that is in another county is not inside your Home Region Service Area unless that other county is listed above and that ZIP code is also listed for that other county.

If you have a question about whether a ZIP code is in your Home Region Service Area, please call our Member Service Contact Center.

Note: We may expand your Home Region Service Area at any time by giving written notice to the Subscriber. ZIP codes are subject to change by the U.S. Postal Service.

Services: Health care services or items ("health care" includes both physical health care and mental health care) and behavioral health treatment covered under "Behavioral Health Treatment for Pervasive Developmental Disorder or Autism" in the "Benefits and Your Cost Share" section.

Skilled Nursing Facility: A facility that provides inpatient skilled nursing care, rehabilitation services, or other related health services and is licensed by the state of California. The facility's primary business must be the provision of 24-hour-a-day licensed skilled nursing care. The term "Skilled Nursing Facility" does not include convalescent nursing homes, rest facilities, or facilities for the aged, if those facilities furnish primarily custodial care, including training in routines of daily living. A "Skilled Nursing Facility" may also be a unit or section within another facility (for example, a hospital) as long as it continues to meet this definition.

Specialty Care Visits: All consultations, evaluations, and treatment that are not Primary Care Visits, including all consultations, evaluations, and treatment provided by personal Plan Physicians who are not Primary Care Physicians.

Spouse: The person to whom the Subscriber is legally married under applicable law. For the purposes of this Membership Agreement and Evidence of Coverage, the term "Spouse" includes the Subscriber's domestic partner. "Domestic partners" are two people who are registered and legally recognized as domestic partners by California.

Stabilize: To provide the medical treatment of the Emergency Medical Condition that is necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the person from the facility. With respect to a pregnant woman who is having contractions, when there is inadequate time to safely transfer her to another hospital before delivery (or the

transfer may pose a threat to the health or safety of the woman or unborn child), "Stabilize" means to deliver (including the placenta).

Subscriber: A Member who is eligible for membership on his or her own behalf and not by virtue of Dependent status and for whom we have received applicable Premiums.

Urgent Care: Medically Necessary Services for a condition that requires prompt medical attention but is not an Emergency Medical Condition.

Premiums, Eligibility, and Enrollment

Premiums Only Members for whom we have received the appropriate Premiums are entitled to coverage under this Membership Agreement and Evidence of Coverage, and then only for the period for which we have received payment. You must prepay the Premiums listed on the Rate Sheet, applicable to your coverage, for each month on or before the last day of the preceding month.

Effective date of Premiums for new Members. Premiums are effective on the same day that your coverage is effective unless you are already enrolled under this Membership Agreement and Evidence of Coverage and are enrolling a new child. If you enroll a child as described under "Special enrollment," Premiums for the child are effective as follows:

• For a newborn, the first of the month following the date of birth

• For an adopted child, the first of the month following the effective date of adoption

• For a child placed with you or your Spouse for adoption, the first of the month following the date you or your Spouse have newly assumed a legal right to control health care. For purposes of this requirement, "legal right to control health care" means you have a signed written document (such as a health facility minor release report, a medical authorization form, or a relinquishment form) or other evidence that shows you or your Spouse have the legal right to control the child's health care

We may amend the Premiums listed on the Rate Sheet by sending written notice at least 60 days before the effective date of the amendment, as described under "Amendment of Membership Agreement and Evidence of Coverage under "Term of this Membership Agreement and Evidence of Coverage,


Renewal, and Amendment" in the "Introduction" section. Also, your Premiums may change as follows:

• When you add a new Dependent, Premiums are effective as described under "Effective date of Premiums for new Members" in this "Premiums" section

• When you drop Dependents or move to a new rate area, any change in Premiums will take effect at the same time the change in coverage becomes effective

• When the Subscriber progresses to a new age band, any change in Premiums will take effect upon renewal

After your first 24 months of individuals and families coverage, we may not increase Premiums solely because you gave us incorrect or incomplete material information in your application for health coverage.

If a government agency or other taxing authority imposes or increases a tax or other charge (other than a tax on or measured by net income) upon Health Plan or Plan Providers (or any of their activities), we may increase Premiums to include your share of the new or increased tax or charge by sending written notice to the Subscriber at least 30 days prior to the effective date of the change. Your share is determined by dividing the number of enrolled Members in your Family by the total number of Members enrolled in your Home Region Service Area.

Who Is Eligible To enroll and to continue enrollment, you must meet all of the eligibility requirements described in this "Who Is Eligible" section.

Service Area eligibility requirements When you join Kaiser Permanente, you are enrolling in one of two Health Plan Regions in California (either our Northern California Region or Southern California Region), which we call your "Home Region." The Service Area of each Region is described in the "Definitions" section of this Membership Agreement and Evidence of Coverage. The Subscriber must live in the Service Area of one of our California Regions at the time he or she enrolls. The coverage information in this Membership Agreement and Evidence of Coverage applies when you obtain care in your Home Region. When you visit the other California Region, you may receive care as described in "Visiting Other Regions" in the "How to Obtain Services" section of this Membership Agreement and Evidence of Coverage.

If the Subscriber moves from your Home Region to the other California Region, we will transfer the membership

of the Subscriber and all Dependents to the Individuals and Families Plan in that Region that is most similar to this plan. All terms and conditions in your application for health coverage, including the Conditions of Acceptance and Arbitration Agreement, will continue to apply. We will provide the Subscriber with the effective date of coverage and a Kaiser Permanente ID card for each Member of the Family with a new medical record number on it. Please refer to the Rate Sheet for the premiums that apply in the other California Region. For more information, please call our Member Service Contact Center.

If the Subscriber moves to the service area of a Region outside California, you may be able to apply for membership in that Region by contacting the member or customer service department there, but the plan, including coverage, premiums, and eligibility requirements, might not be the same as under this Membership Agreement and Evidence of Coverage.

If the Subscriber moves anywhere else outside your Home Region Service Area after enrollment, you can continue your membership as long as you meet all other eligibility requirements. However, you must receive covered Services from Plan Providers inside your Home Region Service Area, except as described in the sections listed below for the following Services: • Authorized referrals as described under "Getting a

Referral" in the "How to Obtain Services" section

• Emergency ambulance Services as described under "Ambulance Services" in the "Benefits and Your Cost Share" section


Hospice care as described under "Hospice Care" in the "Benefits and Your Cost Share" section

Newborn coverage If you are already enrolled under this Membership Agreement and Evidence of Coverage and have a baby, your newborn will automatically be covered for 31 days from the date of birth. If you do not enroll the newborn within 31 days, he or she is covered for only 31 days (including the date of birth).

Eligibility as a Dependent If you are a Subscriber, the following persons are eligible to enroll as your Dependents: • Your Spouse

• Your or your Spouse's Dependent children, who are under age 26, if they are any of the following:


♦ sons, daughters, or stepchildren ♦ adopted children ♦ children placed with you for adoption ♦ children for whom you or your Spouse is the

court-appointed guardian (or was when the child reached age 18)

• Children whose parent is a Dependent under your family coverage (including adopted children and children placed with your Dependent for adoption) if they meet all of the following requirements: ♦ they are not married and do not have a domestic

partner (for the purposes of this requirement only, "domestic partner" means someone who is registered and legally recognized as a domestic partner by California)

♦ they are under age 26 ♦ they receive all of their support and maintenance

from you or your Spouse ♦ they permanently reside with you or your Spouse

• Dependent children of the Subscriber or Spouse (including adopted children and children placed with you for adoption) who reach an age limit may continue coverage under this Membership Agreement and Evidence of Coverage if all of the following conditions are met: ♦ they meet all requirements to be a Dependent

except for the age limit ♦ they are incapable of self-sustaining employment

because of a physically- or mentally-disabling injury, illness, or condition that occurred before they reached age 26

♦ they receive 50 percent or more of their support and maintenance from you or your Spouse

♦ you give us proof of their incapacity and dependency within 60 days after we request it (see "Disabled Dependent certification" below in this "Eligibility as a Dependent" section)

Disabled Dependent certification. One of the requirements for a Dependent to be eligible to continue coverage as a disabled Dependent is that the Subscriber must provide us documentation of the dependent's incapacity and dependency as follows: • If the child is a Member, we will send the Subscriber

a notice of the Dependent's membership termination due to loss of eligibility at least 90 days before the date coverage will end due to reaching the age limit. The Dependent's membership will terminate as described in our notice unless the Subscriber provides us documentation of the Dependent's incapacity and dependency within 60 days of receipt of our notice and we determine that the Dependent is eligible as a

disabled dependent. If the Subscriber provides us this documentation in the specified time period and we do not make a determination about eligibility before the termination date, coverage will continue until we make a determination. If we determine that the Dependent does not meet the eligibility requirements as a disabled dependent, we will notify the Subscriber that the Dependent is not eligible and let the Subscriber know the membership termination date. If we determine that the Dependent is eligible as a disabled dependent, there will be no lapse in coverage. Also, starting two years after the date that the Dependent reached the age limit, the Subscriber must provide us documentation of the Dependent's incapacity and dependency annually within 60 days after we request it so that we can determine if the Dependent continues to be eligible as a disabled dependent

• If the child is not a Member because you are changing coverages, you must give us proof, within 60 days after we request it, of the child's incapacity and dependency as well as proof of the child's coverage under your prior coverage. In the future, you must provide proof of the child's continued incapacity and dependency within 60 days after your receive our request, but not more frequently than annually

Persons barred from enrolling • You cannot enroll if you have had your entitlement to

receive Services through Health Plan terminated for cause

• Persons who have had entitlement to receive Services through Health Plan terminated three times in any 12-month period for failure to pay individual (nongroup) plan premiums cannot enroll for 12 months after the second termination date. For the purposes of this paragraph, a termination does not count if we reinstated your entitlement to receive Services because you made full payment on or before the next scheduled payment due date following the one you missed

How to Enroll and When Coverage Begins How to enroll To request enrollment, you must submit a completed application for health coverage for the Subscriber and any Dependents. Please follow the directions on the enrollment form for how to submit the application. If you are requesting enrollment for a reason listed under "Special enrollment," you may be required to provide


documentation that you have experienced a triggering event.

If you are already enrolled as a Subscriber, the same procedure applies to request enrollment of newly acquired Dependents. When requesting enrollment of a newborn, newly adopted child, or a child placed with you or your Spouse for adoption, the Subscriber must submit an application for health coverage within 60 days after the date of birth, date of adoption, or date that you or your Spouse have newly assumed a legal right to control health care in anticipation of adoption. For purposes of this requirement, "legal right to control health care" means you have a signed written document (such as a health facility minor release report, a medical authorization form, or a relinquishment form) or other evidence that shows you have the legal right to control the child's health care. If you do not enroll the newborn child within 60 days, the newborn is covered for only 31 days (including the date of birth).

Selecting and switching your benefit plan When you first enroll, you must select a plan to enroll in. You cannot switch plans until the next open enrollment period unless you meet the requirements described in the "Special Enrollment" section.

Open enrollment period You may apply for enrollment by submitting an application for health coverage as described in the "How to Enroll" section during the enrollment period of November 15, 2014, through February 15, 2015. If your application is accepted, your membership effective date will be one of the following: • January 1, 2015, if your application is received by

December 15, 2014 • The first day of the next month, if your application is

received by the fifteenth day of a month. For example, if we or Covered California receives your application on January 10, 2015, and then accepts it, your membership effective date would be February 1, 2015

• The first day of the month following the next month, if your application is received after the fifteenth day of a month. For example, if we or Covered California receives your application on January 20, 2015, and then accepts it, your membership effective date would be March 1, 2015

Special enrollment You may apply for enrollment as a Subscriber (and existing Subscribers may apply to enroll Dependents) by submitting an application for health coverage, as described in the "How to Enroll" section, within 60 days

after one of the following triggering events happens to one of the people applying:

• You lose minimum essential coverage (for a reason other than nonpayment of Premiums, termination for cause, or rescission of coverage): ♦ you lose your group health plan coverage (for

example, you lose eligibility as a subscriber because you lose your job or your hours are reduced, you lose eligibility as a dependent due to legal separation, divorce, reaching the age limit for dependent children, or the person who covers you on his or her employer health plan dies, or you exhaust COBRA or Cal-COBRA coverage)

♦ you lose eligibility for individual plan coverage, Medicare, Medi-Cal, or other government-sponsored health care program coverage

♦ your military coverage ended because you returned from active duty

• You gain a Dependent or become a Dependent through marriage, entering into domestic partnership, birth, adoption, placement for adoption, or placement for foster care

• You become eligible for membership as a result of a permanent move

• You were recently released from incarceration

• A state or federal court orders that you (or your dependent) be covered as a dependent

• You are newly eligible or ineligible for advance payment of the premium tax credit or for a cost share reduction

• Your immigration status changes and you are newly eligible to enroll in coverage through Covered California

• You are an American Indian or Native Alaskan and Covered California determines that you are eligible for a monthly special enrollment period

• Covered California determines that you are entitled to a special enrollment period (for example, Covered California determines that you didn't apply for coverage during the prior open enrollment because you were misinformed that you had minimum essential coverage)

• You were under active care for certain conditions with a provider whose participation in your health plan ended (examples of conditions include: an acute condition, a serious chronic condition, pregnancy, terminal illness, care of newborn, or authorized nonelective surgeries


For more information about special enrollment triggering events, visit our website at kp.org or call our Member Service Contact Center.

If your application is accepted, your membership effective date will be one of the following:

• For birth, the date of birth

• For adoption, the date of adoption

• For placement for adoption or foster care, the date you or your Spouse have newly assumed a legal right to control health care. For purposes of this requirement, "legal right to control health care" means you have a signed written document (such as a health facility minor release report, a medical authorization form, or a relinquishment form) or other evidence that shows you or your Spouse have the legal right to control the child's health care

• For marriage, entering into a domestic partnership, or when a person loses minimum essential coverage, the first day of the month following the month when your application is received

• For all other special enrollment events: ♦ the first day of the next month, if your application

is received by the fifteenth day of a month. For example, if your application is received on January 10, 2015 and your request for enrollment is accepted, your membership effective date would be February 1, 2015

♦ the first day of the month following the next month, if your application is received after the fifteenth day of a month. For example, if your application is received on February 20, 2015 and your request for enrollment is accepted, your membership effective date would be April 1, 2015

How to appeal if your application is declined If your request for enrollment is declined, you may appeal this decision using one of the following processes: • If we decline your request for enrollment, you may

appeal by filing a grievance. Please refer to "Grievances" in the "Dispute Resolution" section for information on how to file a grievance

• If Covered California declines your request for enrollment in coverage offered through Covered California, you may appeal by following the process described in Covered California's notice

How to Obtain Services

As a Member, you are selecting our medical care program to provide your health care. You must receive all covered care from Plan Providers inside your Home Region Service Area, except as described in the sections listed below for the following Services: • Authorized referrals as described under "Getting a

Referral" in this "How to Obtain Services" section • Emergency ambulance Services as described under

"Ambulance Services" in the "Benefits and Your Cost Share" section


• Hospice care as described under "Hospice Care" in the "Benefits and Your Cost Share" section

As a Member, you are enrolled in one of two Health Plan Regions in California (either our Northern California Region or Southern California Region), called your Home Region. The coverage information in this Membership Agreement and Evidence of Coverage applies when you obtain care in your Home Region.

Our medical care program gives you access to all of the covered Services you may need, such as routine care with your own personal Plan Physician, hospital care, laboratory and pharmacy Services, Emergency Services, Urgent Care, and other benefits described in the "Benefits and Your Cost Share" section.

Routine Care If you need the following Services, you should schedule an appointment:

• Preventive Care Services

• Periodic follow-up care (regularly scheduled follow-up care, such as visits to monitor a chronic condition)

• Other care that is not Urgent Care

To make a non-urgent appointment, please refer to Your Guidebook for appointment telephone numbers, or go to our website at kp.org to request an appointment online.

Urgent Care An Urgent Care need is one that requires prompt medical attention but is not an Emergency Medical Condition. If you think you may need Urgent Care, call the appropriate appointment or advice telephone number at a


Plan Facility. Please refer to Your Guidebook for appointment and advice telephone numbers.

For information about Out-of-Area Urgent Care, please refer to "Urgent Care" in the "Emergency Services and Urgent Care" section.

Not Sure What Kind of Care You Need? Sometimes it's difficult to know what kind of care you need, so we have licensed health care professionals available to assist you by phone 24 hours a day, seven days a week. Here are some of the ways they can help you: • They can answer questions about a health concern,

and instruct you on self-care at home if appropriate

• They can advise you about whether you should get medical care, and how and where to get care (for example, if you are not sure whether your condition is an Emergency Medical Condition, they can help you decide whether you need Emergency Services or Urgent Care, and how and where to get that care)

• They can tell you what to do if you need care and a Plan Medical Office is closed or you are outside your Home Region Service Area

You can reach one of these licensed health care professionals by calling the appointment or advice telephone number listed in Your Guidebook. When you call, a trained support person may ask you questions to help determine how to direct your call.

Your Personal Plan Physician Personal Plan Physicians provide primary care and play an important role in coordinating care, including hospital stays and referrals to specialists.

We encourage you to choose a personal Plan Physician. You may choose any available personal Plan Physician. Parents may choose a pediatrician as the personal Plan Physician for their child. Most personal Plan Physicians are Primary Care Physicians (generalists in internal medicine, pediatrics, or family practice, or specialists in obstetrics/gynecology whom the Medical Group designates as Primary Care Physicians). Some specialists who are not designated as Primary Care Physicians but who also provide primary care may be available as personal Plan Physicians. For example, some specialists in internal medicine and obstetrics/gynecology who are not designated as Primary Care Physicians may be available as personal Plan Physicians. However, if you choose a specialist who is not designated as a Primary

Care Physician as your personal Plan Physician, the Cost Share for a Specialty Care Visit will apply to all visits with the specialist except for routine preventive care visits listed under "Outpatient Care" in the "Benefits and Your Cost Share" section.

To learn how to select or change to a different personal Plan Physician, please refer to Your Guidebook or call our Member Service Contact Center. You can find a directory of our Plan Physicians on our website at kp.org. For the current list of physicians that are available as Primary Care Physicians, please call the personal physician selection department at the phone number listed in Your Guidebook. You can change your personal Plan Physician at any time for any reason.

Getting a Referral Referrals to Plan Providers A Plan Physician must refer you before you can receive care from specialists, such as specialists in surgery, orthopedics, cardiology, oncology, urology, dermatology, and physical, occupational, and speech therapies. Also, a Plan Physician must refer you before you can get care from Qualified Autism Service Providers covered under "Behavioral Health Treatment for Pervasive Developmental Disorder or Autism" in the "Benefits and Your Cost Share" section. However, you do not need a referral or prior authorization to receive most care from any of the following Plan Providers: • Your personal Plan Physician

• Generalists in internal medicine, pediatrics, and family practice

• Specialists in optometry, psychiatry, chemical dependency, and obstetrics/gynecology

Although a referral or prior authorization is not required to receive most care from these providers, a referral may be required in the following situations: • The provider may have to get prior authorization for

certain Services in accord with "Medical Group authorization procedure for certain referrals" in this "Getting a Referral" section

• The provider may have to refer you to a specialist who has a clinical background related to your illness or condition


Standing referrals If a Plan Physician refers you to a specialist, the referral will be for a specific treatment plan. Your treatment plan may include a standing referral if ongoing care from the specialist is prescribed. For example, if you have a life-threatening, degenerative, or disabling condition, you can get a standing referral to a specialist if ongoing care from the specialist is required.

Medical Group authorization procedure for certain referrals The following are examples of Services that require prior authorization by the Medical Group for the Services to be covered ("prior authorization" means that the Medical Group must approve the Services in advance):

• Durable medical equipment

• Ostomy and urological supplies

• Services not available from Plan Providers

• Transplants

For the complete list of Services that require prior authorization, and the criteria that are used to make authorization decisions, please visit our website at kp.org or call our Member Service Contact Center. Please refer to "Post-Stabilization Care" under "Emergency Services" in the "Emergency Services and Urgent Care" section for authorization requirements that apply to Post-Stabilization Care from Non–Plan Providers.

Decisions regarding requests for authorization will be made only by licensed physicians or other appropriately licensed medical professionals.

Medical Group's decision time frames. The applicable Medical Group designee will make the authorization decision within the time frame appropriate for your condition, but no later than five business days after receiving all of the information (including additional examination and test results) reasonably necessary to make the decision, except that decisions about urgent Services will be made no later than 72 hours after receipt of the information reasonably necessary to make the decision. If the Medical Group needs more time to make the decision because it doesn't have information reasonably necessary to make the decision, or because it has requested consultation by a particular specialist, you and your treating physician will be informed about the additional information, testing, or specialist that is needed, and the date that the Medical Group expects to make a decision.

Your treating physician will be informed of the decision within 24 hours after the decision is made. If the Services are authorized, your physician will be informed of the

scope of the authorized Services. If the Medical Group does not authorize all of the Services, Health Plan will send you a written decision and explanation within two business days after the decision is made. Any written criteria that the Medical Group uses to make the decision to authorize, modify, delay, or deny the request for authorization will be made available to you upon request.

If the Medical Group does not authorize all of the Services requested and you want to appeal the decision, you can file a grievance as described under "Grievances" in the "Dispute Resolution" section.

Your Cost Share. Your Cost Share for these referral Services is the Cost Share required for Services provided by a Plan Provider as described in the "Benefits and Your Cost Share" section.

Second Opinions If you want a second opinion, you can either ask your Plan Physician to help you arrange one, or you can make an appointment with another Plan Physician. If there isn't a Plan Physician who is an appropriately qualified medical professional for your condition, the appropriate Medical Group designee will authorize a consultation with a Non–Plan Physician for a second opinion. For purposes of this "Second Opinions" provision, an "appropriately qualified medical professional" is a physician who is acting within his or her scope of practice and who possesses a clinical background related to the illness or condition associated with the request for a second medical opinion.

Here are some examples of when a second opinion may be provided or authorized: • Your Plan Physician has recommended a procedure

and you are unsure about whether the procedure is reasonable or necessary

• You question a diagnosis or plan of care for a condition that threatens substantial impairment or loss of life, limb, or bodily functions

• The clinical indications are not clear or are complex and confusing

• A diagnosis is in doubt due to conflicting test results • The Plan Physician is unable to diagnose the

condition • The treatment plan in progress is not improving your

medical condition within an appropriate period of time, given the diagnosis and plan of care

• You have concerns about the diagnosis or plan of care


You have a right to a second opinion. If you have requested a second opinion and you have not received it or you believe it has not been authorized, you can file a grievance as described under "Grievances" in the "Dispute Resolution" section.

Your Cost Share. Your Cost Share for these referral Services is the Cost Share required for Services provided by a Plan Provider as described in the "Benefits and Your Cost Share" section.

Interactive Video Visits Interactive video visits between you and your provider are intended to make it more convenient for you to receive covered Services, when a Plan Provider determines it is medically appropriate for your medical condition. You may receive covered Services via interactive video visits, when available and if the Services would have been covered under the "Benefits and Your Cost Share" section (subject to the "Exclusions, Limitations, Coordination of Benefits, and Reductions" section) if provided in person. You are not required to use interactive video visits. If you do agree to use interactive video visits, you may be charged Cost Share for the Services you receive. (For example, if you have an interactive video visit consultation with a specialist, you may be charged the specialty care visit Cost Share.)

Contracts with Plan Providers How Plan Providers are paid Health Plan and Plan Providers are independent contractors. Plan Providers are paid in a number of ways, such as salary, capitation, per diem rates, case rates, fee for service, and incentive payments. To learn more about how Plan Physicians are paid to provide or arrange medical and hospital care for Members, please visit our website at kp.org or call our Member Service Contact Center.

Financial liability Our contracts with Plan Providers provide that you are not liable for any amounts we owe. However, you may have to pay the full price of noncovered Services you obtain from Plan Providers or Non–Plan Providers.

Breach of contract We will give you written notice within a reasonable time if any contracted provider breaches a contract with us, or is not able to provide contracted Services, if you might be materially and adversely affected.

Termination of a Plan Provider's contract and completion of Services If our contract with any Plan Provider terminates while you are under the care of that provider, we will retain financial responsibility for covered care you receive from that provider until we make arrangements for the Services to be provided by another Plan Provider and notify you of the arrangements. We will send you written notice 60 days before the effective date of the termination (or as soon as reasonably possible) if a contracted provider group or hospital terminates a contract with us and you might be materially and adversely affected.

In addition, if you are currently receiving covered Services in one of the following cases from a Plan Hospital or a Plan Physician (or certain other providers) when our contract with the provider ends (for reasons other than medical disciplinary cause or criminal activity), you may be eligible for limited coverage of that terminated provider's Services: • Acute conditions, which are medical conditions that

involve a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and has a limited duration. We may cover these Services until the acute condition ends

• We may cover Services for serious chronic conditions until the earlier of (1) 12 months from the termination date of the terminated provider, or (2) the first day after a course of treatment is complete when it would be safe to transfer your care to a Plan Provider, as determined by Kaiser Permanente after consultation with the Member and Non–Plan Provider and consistent with good professional practice. Serious chronic conditions are illnesses or other medical conditions that are serious, if one of the following is true about the condition: ♦ it persists without full cure ♦ it worsens over an extended period of time ♦ it requires ongoing treatment to maintain

remission or prevent deterioration • Pregnancy and immediate postpartum care. We may

cover these Services for the duration of the pregnancy and immediate postpartum care

• Terminal illnesses, which are incurable or irreversible illnesses that have a high probability of causing death within a year or less. We may cover completion of these Services for the duration of the illness

• Care for children under age 3. We may cover completion of these Services until the earlier of (1) 12 months from the termination date of the terminated provider, or (2) the child's third birthday


• Surgery or another procedure that is documented as part of a course of treatment and has been recommended and documented by the provider to occur within 180 days of the termination date of the terminated provider

To qualify for this completion of Services coverage, all of the following requirements must be met: • Your Health Plan coverage is in effect on the date

you receive the Service

• You are receiving Services in one of the cases listed above from the terminated Plan Provider on the provider's termination date

• The provider agrees to our standard contractual terms and conditions, such as conditions pertaining to payment and to providing Services inside your Home Region Service Area (the requirement that the provider agree to providing Services inside your Home Region Service Area doesn't apply if you were receiving covered Services from the provider outside the Service Area when the provider's contract terminated)

• The Services to be provided to you would be covered Services under this Membership Agreement and Evidence of Coverage if provided by a Plan Provider

• You request completion of Services within 30 days (or as soon as reasonably possible) from the termination date of the Plan Provider

Your Cost Share. Your Cost Share for completion of Services is the Cost Share required for Services provided by a Plan Provider as described in the "Benefits and Your Cost Share" section.

More information. For more information about this provision, or to request the Services or a copy of our "Completion of Covered Services" policy, please call our Member Service Contact Center.

Visiting Other Regions If you visit the service area of another Region temporarily (not more than 90 days), you can receive visiting member care from designated providers in that area. Visiting member care is described in our visiting member brochure. Visiting member care and your out-of-pocket costs may differ from the covered Services and Cost Share described in this Membership Agreement and Evidence of Coverage.

The 90-day limit on visiting member care does not apply to Members who attend an accredited college or accredited vocational school. The service areas and

facilities where you may obtain visiting member care may change at any time without notice.

Please call our Member Service Contact Center for more information about visiting member care, including facility locations in the service area of another Region, and to request a copy of the visiting member brochure.

Your ID Card Each Member's Kaiser Permanente ID card has a medical record number on it, which you will need when you call for advice, make an appointment, or go to a provider for covered care. When you get care, please bring your Kaiser Permanente ID card and a photo ID. Your medical record number is used to identify your medical records and membership information. Your medical record number should never change. Please call our Member Service Contact Center if we ever inadvertently issue you more than one medical record number or if you need to replace your Kaiser Permanente ID card.

Your ID card is for identification only. To receive covered Services, you must be a current Member. Anyone who is not a Member will be billed as a non-Member for any Services he or she receives. If you let someone else use your ID card, we may keep your ID card and terminate your membership as described under "Termination for Cause" in the "Termination of Membership" section.

Getting Assistance We want you to be satisfied with the health care you receive from Kaiser Permanente. If you have any questions or concerns, please discuss them with your personal Plan Physician or with other Plan Providers who are treating you. They are committed to your satisfaction and want to help you with your questions.

Member Services Many Plan Facilities have an office staffed with representatives who can provide assistance if you need help obtaining Services. At different locations, these offices may be called Member Services, Patient Assistance, or Customer Service. In addition, our Member Service Contact Center representatives are available to assist you toll free 24 hours a day, seven days a week (except closed holidays, and closed after 5 p.m. the day after Thanksgiving, after 5 p.m. on Christmas Eve, and after 5 p.m. on New Year's Eve) as follows: • English: 1-800-464-4000

• Spanish: 1-800-788-0616


• Chinese dialects: 1-800-757-7585

• TTY for the deaf, hard of hearing, or speech impaired: 1-800-777-1370 or 711

For your convenience, you can also contact us through our website at kp.org.

Member Services representatives at our Plan Facilities and Member Service Contact Center can answer any questions you have about your benefits, available Services, and the facilities where you can receive care. For example, they can explain your Health Plan benefits, how to make your first medical appointment, what to do if you move, what to do if you need care while you are traveling, and how to replace your ID card. These representatives can also help you if you need to file a claim as described in the "Emergency Services and Urgent Care" section or with any issues as described in the "Dispute Resolution" section.

Interpreter services If you need interpreter services when you call us or when you get covered Services, please let us know. Interpreter services, including sign language, are available during all business hours at no cost to you. For more information on the interpreter services we offer, please call our Member Service Contact Center.

Plan Facilities

Plan Medical Offices and Plan Hospitals for your area are listed in Your Guidebook to Kaiser Permanente Services (Your Guidebook) and on our website at kp.org. Your Guidebook describes the types of covered Services that are available from each Plan Facility in your area, because some facilities provide only specific types of covered Services. Also, it explains how to use our Services and make appointments, lists hours of operation, and includes a detailed telephone directory for appointments and advice. If you have any questions about the current locations of Plan Medicals Offices and/or Plan Hospitals, please call our Member Service Contact Center.

At most of our Plan Facilities, you can usually receive all of the covered Services you need, including specialty care, pharmacy, and lab work. You are not restricted to a particular Plan Facility, and we encourage you to use the facility that will be most convenient for you: • All Plan Hospitals provide inpatient Services and are

open 24 hours a day, seven days a week

• Emergency Services are available from Plan Hospital Emergency Departments as described in Your

Guidebook (please refer to Your Guidebook for Emergency Department locations in your area)

• Same–day Urgent Care appointments are available at many locations (please refer to Your Guidebook for Urgent Care locations in your area)

• Many Plan Medical Offices have evening and weekend appointments

• Many Plan Facilities have a Member Services Department (refer to Your Guidebook for locations in your area)

Note: State law requires evidence of coverage documents to include the following notice:

Some hospitals and other providers do not provide one or more of the following services that may be covered under your plan contract and that you or your family member might need: family planning; contraceptive services, including emergency contraception; sterilization, including tubal ligation at the time of labor and delivery; infertility treatments; or abortion. You should obtain more information before you enroll. Call your prospective doctor, medical group, independent practice association, or clinic, or call the Kaiser Permanente Member Service Contact Center, to ensure that you can obtain the health care services that you need.

Please be aware that if a Service is covered but not available at a particular Plan Facility, we will make it available to you at another facility.

Emergency Services and Urgent Care

Emergency Services If you have an Emergency Medical Condition, call 911 (where available) or go to the nearest hospital Emergency Department. You do not need prior authorization for Emergency Services. When you have an Emergency Medical Condition, we cover Emergency Services you receive from Plan Providers or Non–Plan Providers anywhere in the world if the Services would have been covered under the "Benefits and Your Cost Share" section (subject to the "Exclusions, Limitations,


Coordination of Benefits, and Reductions" section) if you had received them from Plan Providers.

Emergency Services are available from Plan Hospital Emergency Departments 24 hours a day, seven days a week.

Post-Stabilization Care Post-Stabilization Care is Medically Necessary Services related to your Emergency Medical Condition that you receive in a hospital (including the Emergency Department) after your treating physician determines that this condition is Stabilized. We cover Post-Stabilization Care from a Non–Plan Provider only if we provide prior authorization for the care or if otherwise required by applicable law ("prior authorization" means that we must approve the Services in advance).

To request prior authorization, the provider must call 1-800-225-8883 or the notification telephone number on your Kaiser Permanente ID card before you receive the care. We will discuss your condition with the Non–Plan Provider. If we determine that you require Post-Stabilization Care and that this care would be covered if you received it from a Plan Provider, we will authorize your care from the Non–Plan Provider or arrange to have a Plan Provider (or other designated provider) provide the care. If we decide to have a Plan Hospital, Plan Skilled Nursing Facility, or designated Non–Plan Provider provide your care, we may authorize special transportation services that are medically required to get you to the provider. This may include transportation that is otherwise not covered.

Be sure to ask the Non–Plan Provider to tell you what care (including any transportation) we have authorized because we will not cover unauthorized Post-Stabilization Care or related transportation provided by Non–Plan Providers. If you receive care from a Non–Plan Provider that we have not authorized, you may have to pay the full cost of that care. If you are admitted to a Non–Plan Hospital, please notify us as soon as possible by calling 1-800-225-8883 or the notification telephone number on your Kaiser Permanente ID card.

Your Cost Share Your Cost Share for covered Emergency Services and Post-Stabilization Care is the Cost Share that you would pay if a Plan Provider had provided the Services and the Services were not Emergency Services or Post-Stabilization Care. For example: • If you receive Emergency Services in the Emergency

Department of a Non–Plan Hospital, you pay the Cost Share for an Emergency Department visit as described under "Outpatient Care"

• If we gave prior authorization for inpatient Post-Stabilization Care in a Non–Plan Hospital, you pay the Cost Share for hospital inpatient care as described under "Hospital Inpatient Care"

Urgent Care Inside the Service Area An Urgent Care need is one that requires prompt medical attention but is not an Emergency Medical Condition. If you think you may need Urgent Care, call the appropriate appointment or advice telephone number at a Plan Facility. Please refer to Your Guidebook for appointment and advice telephone numbers.

Out-of-Area Urgent Care If you need Urgent Care due to an unforeseen illness, unforeseen injury, or unforeseen complication of an existing condition (including pregnancy), we cover Medically Necessary Services to prevent serious deterioration of your (or your unborn child's) health from a Non–Plan Provider if all of the following are true: • You receive the Services from Non–Plan Providers

while you are temporarily outside your Home Region Service Area

• A reasonable person would have believed that your (or your unborn child's) health would seriously deteriorate if you delayed treatment until you returned to your Home Region Service Area

You do not need prior authorization for Out-of-Area Urgent Care. We cover Out-of-Area Urgent Care you receive from Non–Plan Providers if the Services would have been covered under the "Benefits and Your Cost Share" section (subject to the "Exclusions, Limitations, Coordination of Benefits, and Reductions" section) if you had received them from Plan Providers.

We do not cover follow-up care from Non–Plan Providers after you no longer need Urgent Care. To obtain follow-up care from a Plan Provider, call the appointment or advice telephone number listed in Your Guidebook.

Your Cost Share Your Cost Share for covered Urgent Care is the Cost Share required for Services provided by Plan Providers as described in the "Benefits and Your Cost Share" section. For example: • If you receive an Urgent Care evaluation as part of

covered Out-of-Area Urgent Care from a Non–Plan Provider, you pay the Cost Share for Urgent Care consultations, evaluations, and treatment as described under "Outpatient Care"


• If the Out-of-Area Urgent Care you receive includes an X-ray, you pay the Cost Share for an X-ray as described under "Outpatient Imaging, Laboratory, and Special Procedures" in addition to the Cost Share for the Urgent Care evaluation

Note: If you receive Urgent Care in an Emergency Department, you pay the Cost Share for an Emergency Department visit as described under "Outpatient Care."

Payment and Reimbursement If you receive Emergency Services, Post-Stabilization Care, or Out-of-Area Urgent Care from a Non–Plan Provider as described in this "Emergency Services and Urgent Care" section, or emergency ambulance Services described under "Ambulance Services" in the "Benefits and Your Cost Share" section, you are not responsible for any amounts beyond your Cost Share for covered Emergency Services. However, if the provider does not agree to bill us, you may have to pay for the Services and file a claim for reimbursement. Also, you may be required to pay and file a claim for any Services prescribed by a Non–Plan Provider as part of covered Emergency Services, Post-Stabilization Care, and Out-of-Area Urgent Care even if you receive the Services from a Plan Provider, such as a Plan Pharmacy.

We will reduce any payment we make to you or the Non–Plan Provider by applicable Cost Share. Also, we will reduce our payment by any amounts paid or payable (or that in the absence of this plan would have been payable) for the Services under any insurance policy, or any other contract or coverage, or any government program except Medicaid. If payment under the other insurance or program is not made within a reasonable period of time, we will pay for covered Emergency Services, Post-Stabilization Care, and Out-of-Area Urgent Care received from Non–Plan Providers if you: • Assign all rights to payment to us and agree to

cooperate with us in obtaining payment • Allow us to obtain any relevant information from the

other insurance or program • Provide us with any information and assistance we

need to obtain payment from the other insurance or program

For information on how to file a claim, please see the "Post-Service Claims and Appeals" section.

Benefits and Your Cost Share

We cover the Services described in this "Benefits and Your Cost Share" section, subject to the "Exclusions, Limitations, Coordination of Benefits, and Reductions" section, only if all of the following conditions are satisfied: • You are a Member on the date that you receive the

Services • The Services are Medically Necessary

• The Services are one of the following: ♦ Preventive Care Services ♦ health care items and services for diagnosis,

assessment, or treatment ♦ health education covered under "Health

Education" in this "Benefits and Your Cost Share" section

♦ other health care items and services

• The Services are provided, prescribed, authorized, or directed by a Plan Physician except where specifically noted to the contrary in the sections listed below for the following Services: ♦ drugs prescribed by dentists as described under

"Outpatient Prescription Drugs, Supplies, and Supplements" in this "Benefits and Your Cost Share" section

♦ emergency ambulance Services as described under "Ambulance Services" in this "Benefits and Your Cost Share" section

♦ Emergency Services, Post-Stabilization Care, and Out-of-Area Urgent Care as described in the "Emergency Services and Urgent Care" section

♦ eyeglasses and contact lenses prescribed by Non–Plan Providers as described under "Vision Services" in this "Benefits and Your Cost Share" section

• You receive the Services from Plan Providers inside your Home Region Service Area, except where specifically noted to the contrary in the sections listed below for the following Services: ♦ authorized referrals as described under "Getting a

Referral" in the "How to Obtain Services" section ♦ emergency ambulance Services as described under

"Ambulance Services" in this "Benefits and Your Cost Share" section

♦ Emergency Services, Post-Stabilization Care, and Out-of-Area Urgent Care as described in the "Emergency Services and Urgent Care" section

♦ hospice care as described under "Hospice Care" in this "Benefits and Your Cost Share" section


• The Medical Group has given prior authorization for the Services if required under "Medical Group authorization procedure for certain referrals" in the "How to Obtain Services" section

The only Services we cover under this Membership Agreement and Evidence of Coverage are those that this "Benefits and Your Cost Share" section says that we cover, subject to exclusions and limitations described in this "Benefits and Your Cost Share" section and to all provisions in the "Exclusions, Limitations, Coordination of Benefits, and Reductions" section. The "Exclusions, Limitations, Coordination of Benefits, and Reductions" section describes exclusions, limitations, reductions, and coordination of benefits provisions that apply to all Services that would otherwise be covered. When an exclusion or limitation applies only to a particular benefit, it is listed in the description of that benefit in this "Benefits and Your Cost Share" section. Also, please refer to: • The "Emergency Services and Urgent Care" section

for information about how to obtain covered Emergency Services, Post-Stabilization Care, and Out-of-Area Urgent Care

• Your Guidebook for the types of covered Services that are available from each Plan Facility in your area, because some facilities provide only specific types of covered Services

Your Cost Share Your Cost Share is the amount you are required to pay for covered Services. The Cost Share for covered Services is listed in this "Benefits and Your Cost Share" section. For example, your Cost Share may be a Copayment or Coinsurance. If your coverage includes a Plan Deductible and you receive Services that are subject to the Plan Deductible, your Cost Share for those Services will be Charges if you have not met the Plan Deductible.

General rules, examples, and exceptions Your Cost Share for covered Services will be the Cost Share in effect on the date you receive the Services, except as follows: • If you are receiving covered inpatient hospital or

Skilled Nursing Facility Services on the effective date of this Membership Agreement and Evidence of Coverage, you pay the Cost Share in effect on your admission date until you are discharged if the Services were covered under your prior Health Plan evidence of coverage and there has been no break in coverage. However, if the Services were not covered under your prior Health Plan membership agreement

and evidence of coverage, or if there has been a break in coverage, you pay the Cost Share in effect on the date you receive the Services

• For items ordered in advance, you pay the Cost Share in effect on the order date (although we will not cover the item unless you still have coverage for it on the date you receive it) and you may be required to pay the Cost Share when the item is ordered. For outpatient prescription drugs, the order date is the date that the pharmacy processes the order after receiving all of the information they need to fill the prescription

Cost Share for Services received by newborn children of a Member. During the 31 days of automatic coverage for newborn children described under "Newborn coverage" under "Who Is Eligible" in the "Premiums, Eligibility, and Enrollment" section, the parent or guardian of the newborn must pay the Cost Share indicated in this "Benefits and Your Cost Share" section for any Services that the newborn receives, whether or not the newborn is enrolled. When the Cost Share for the Services is described as "subject to the Plan Deductible," the Cost Share for those Services will be Charges if the newborn has not met the Plan Deductible.

Payment toward your Cost Share (and when you may be billed). In most cases, your provider will ask you to make a payment toward your Cost Share at the time you receive Services. If you receive more than one type of Services (such as a routine physical maintenance exam and laboratory tests), you may be required to pay separate Cost Shares for each of those Services. Keep in mind that your payment toward your Cost Share may cover only a portion of your total Cost Share for the Services you receive, and you will be billed for any additional amounts that are due. The following are examples of when you may be asked to pay (or you may be billed for) Cost Share amounts in addition to the amount you pay at check-in:

• You receive non-preventive Services during a preventive visit. For example, you go in for a routine physical maintenance exam, and at check-in you pay your Cost Share for the preventive exam (your Cost Share may be "no charge"). However, during your preventive exam your provider finds a problem with your health and orders non-preventive Services to diagnose your problem (such as laboratory tests). You may be asked to pay (or you will be billed for) your Cost Share for these additional non-preventive diagnostic Services

• You receive diagnostic Services during a treatment visit. For example, you go in for treatment of an existing health condition, and at check-in you pay your Cost Share for a treatment visit. However,


during the visit your provider finds a new problem with your health and performs or orders diagnostic Services (such as laboratory tests). You may be asked to pay (or you will be billed for) your Cost Share for these additional diagnostic Services

• You receive treatment Services during a diagnostic visit. For example, you go in for a diagnostic exam, and at check-in you pay your Cost Share for a diagnostic exam. However, during the diagnostic exam your provider confirms a problem with your health and performs treatment Services (such as an outpatient procedure). You may be asked to pay (or you will be billed for) your Cost Share for these additional treatment Services

• You receive Services from a second provider during your visit. For example, you go in for a diagnostic exam, and at check-in you pay your Cost Share for a diagnostic exam. However, during the diagnostic exam your provider requests a consultation with a specialist. You may be asked to pay (or you will be billed for) your Cost Share for the consultation with the specialist

In some cases, your provider will not ask you to make a payment at the time you receive Services, and you will be billed for your Cost Share. The following are examples of when you will be billed: • A Plan Provider is not able to collect Cost Share at

the time you receive Services (for example, some Laboratory Departments are not able to collect Cost Shares)

• You ask to be billed for some or all of your Cost Share

• Medical Group authorizes a referral to a Non–Plan Provider and that provider does not collect your Cost Share at the time you receive Services

• You receive covered Emergency Services or Out-of-Area Urgent Care from a Non–Plan Provider and that provider does not collect your Cost Share at the time you receive Services

If you have questions about a bill, please call the phone number on the bill.

Primary Care Visits and Specialty Care Visits. The Cost Share for a Primary Care Visit applies to evaluations and treatment provided by generalists in internal medicine, pediatrics, or family practice, and by specialists in obstetrics/gynecology whom the Medical Group designates as Primary Care Physicians. Some specialists provide primary care in addition to specialty care but are not designated as Primary Care Physicians. If you receive Services from one of these specialists, the

Cost Share for a Specialty Care Visit will apply to all consultations, evaluations, and treatment provided by the specialist except for routine preventive care counseling and exams listed under "Outpatient Care" in this "Benefits and Your Cost Share" section. For example, if your personal Plan Physician is a specialist in internal medicine or obstetrics/gynecology who is not a Primary Care Physician, you will pay the Cost Share for a Specialty Care Visit for all consultations, evaluations, and treatment by the specialist except routine preventive care counseling and exams listed under "Outpatient Care" in this "Benefits and Your Cost Share" section.

Noncovered Services. If you receive Services that are not covered under this Membership Agreement and Evidence of Coverage, you may have to pay the full price of those Services. Payments you make for noncovered Services do not apply to any deductible or out-of-pocket maximum.

Copayments and Coinsurance The Copayment or Coinsurance you must pay for each covered Service, after you meet any applicable deductible, is described in this "Benefits and Your Cost Share" section.

Note: If Charges for Services are less than the Copayment described in this "Benefits and Your Cost Share" section, you will pay the lesser amount.

Out-of-pocket maximum There is a limit to the total amount of Cost Share you must pay under this Membership Agreement and Evidence of Coverage in the calendar year for covered Services that you receive in the same calendar year. The Services that apply to the maximum are described under the "Payments that count toward the maximum" section below. The limit is one of the following amounts:

• $4,000 per calendar year for self-only enrollment (a Family of one Member)

• $4,000 per calendar year for any one Member in a Family of two or more Members

• $8,000 per calendar year for an entire Family of two or more Members

If you are a Member in a Family of two or more Members, you reach the out-of-pocket maximum either when you meet the maximum for any one Member, or when your Family reaches the Family maximum. For example, suppose you have reached the $4,000 maximum. You will not pay any more Cost Share during the rest of the calendar year, but every other Member in your Family must continue to pay Cost Share during the


calendar year until your Family reaches the $8,000 maximum.

Payments that count toward the maximum. Any payments you make toward the Plan Deductible, if applicable, apply toward the maximum.

Also, Copayments and Coinsurance you pay for covered Services apply to the maximum, except as described below:

• If your plan includes supplemental chiropractic or acupuncture Services described in an Amendment to this Membership Agreement and Evidence of Coverage, those Services do not apply toward the maximum

• If your plan includes an Allowance for specific Services (such as eyeglasses, contact lenses, or hearing aids), any amounts you pay that exceed the Allowance do not apply toward the maximum

If your plan includes pediatric dental Services described in a Pediatric Dental Services Amendment to this Membership Agreement and Evidence of Coverage, those Services will apply toward the maximum.

Keeping track of the maximum. When you receive Services that are subject to the maximum, we will give you a receipt. To find out your total accumulation, check your coverage information on kp.org or call our Member Service Contact Center.

Preventive Care Services We cover a variety of Preventive Care Services. This "Preventive Care Services" section explains the Cost Share for some Preventive Care Services, but it does not otherwise explain coverage. For coverage of Preventive Care Services, please refer to the applicable benefit heading in this "Benefits and Your Cost Share" section, subject to the "Exclusions, Limitations, Coordination of Benefits, and Reductions" section. For example, for coverage of outpatient imaging Services, please refer to the "Outpatient Imaging, Laboratory, and Special Procedures" section, subject to the "Exclusions, Limitations, Coordination of Benefits, and Reductions" section.

We cover at no charge the Preventive Care Services on the health care reform preventive care Services list for Members enrolled in our California Regions. This list is subject to change at any time and is available on the preventive care page on our website at kp.org/prevention or by calling our Member Service Contact Center. Note: If you receive any other covered Services during a visit that includes Preventive Care

Services on the list, you will pay the applicable Cost Share for those other Services.

The following are examples of Preventive Care Services that are included in our health care reform preventive care Services list:

• Routine physical maintenance exams, including well-woman exams (refer to "Outpatient Care")

• Scheduled routine prenatal exams (refer to "Outpatient Care")

• Well-child exams for children 0-23 months (refer to "Outpatient Care")

• Health education counseling programs (refer to "Health Education")

• Immunizations (refer to "Outpatient Care")

• Routine preventive imaging and laboratory Services (refer to "Outpatient Imaging, Laboratory, and Special Procedures")

Outpatient Care We cover the following outpatient care subject to the Cost Share indicated: • Primary Care Visits (evaluations and treatment

provided by generalists in internal medicine, pediatrics, or family medicine, and by specialists in obstetrics/gynecology whom the Medical Group designates as Primary Care Physicians) other than those described below in this "Outpatient Care" section: a $20 Copayment per visit

• Specialty Care Visits (all consultations, evaluations, and treatment that are not Primary Care Visits, including all consultations, evaluations, and treatment provided by personal Plan Physicians who are not Primary Care Physicians) other than those described below in this "Outpatient Care" section: a $40 Copayment per visit

• Preventive Care Services: ♦ routine physical maintenance exams, including

well-woman exams: no charge ♦ screening and counseling Services, such as obesity

counseling, routine vision and hearing screenings, health education, and depression screening when performed during a routine physical maintenance exam: no charge

♦ well-child preventive exams for Members through age 23 months: no charge

♦ after confirmation of pregnancy, the normal series of regularly scheduled preventive prenatal care exams: no charge


♦ the first postpartum follow-up consultation and exam: no charge

♦ comprehensive breastfeeding support and counseling: no charge

♦ alcohol and substance abuse screenings: no charge

♦ developmental screenings to diagnose and assess potential developmental delays: no charge

♦ immunizations (including the vaccine) administered to you in a Plan Medical Office: no charge

♦ flexible sigmoidoscopies: no charge ♦ screening colonoscopies: no charge

• Allergy injections (including allergy serum): a $5 Copayment per visit

• Outpatient surgery and outpatient procedures when provided in an outpatient or ambulatory surgery center or in a hospital operating room, or if it is provided in any setting and a licensed staff member monitors your vital signs as you regain sensation after receiving drugs to reduce sensation or to minimize discomfort: a $250 Copayment per procedure

• Any other outpatient surgery that does not require a licensed staff member to monitor your vital signs as described above: a $40 Copayment per procedure

• Any other outpatient procedures that do not require a licensed staff member to monitor your vital signs as described above: the Cost Share that would otherwise apply for the procedure in this "Benefits and Your Cost Share" section (for example, radiology procedures that do not require a licensed staff member to monitor your vital signs as described above are covered under "Outpatient Imaging, Laboratory, and Special Procedures")

• Urgent Care consultations, evaluations, and treatment: a $20 Copayment per visit

• Emergency Department visits: a $150 Copayment per visit. The Emergency Department Copayment does not apply if you are admitted directly to the hospital as an inpatient for covered Services, or if you are admitted for observation and are then admitted directly to the hospital as an inpatient for covered Services (for inpatient care, please refer to "Hospital Inpatient Care" in this "Benefits and Your Cost Share" section). However, the Emergency Department Copayment does apply if you are admitted for observation but are not admitted as an inpatient

• House calls by a Plan Physician (or a Plan Provider who is a registered nurse) inside your Home Region Service Area when care can best be provided in your home as determined by a Plan Physician: no charge

• Acupuncture Services (typically provided only for the treatment of nausea or as part of a comprehensive pain management program for the treatment of chronic pain): a $40 Copayment per visit

• Blood, blood products, and their administration: no charge

• Administered drugs (drugs, injectables, radioactive materials used for therapeutic purposes, and allergy test and treatment materials) prescribed in accord with our drug formulary guidelines, if administration or observation by medical personnel is required and they are administered to you in a Plan Medical Office or during home visits: ♦ tuberculosis tests: no charge ♦ administered chemotherapy drugs: no charge ♦ all other administered drugs: no charge

• Outpatient consultations, evaluations, and treatment that are available as group appointments: a $10 Copayment per visit

Coverage for Services related to "Outpatient Care" described in other sections The following types of outpatient Services are covered only as described under these headings in this "Benefits and Your Cost Share" section: • Bariatric Surgery

• Behavioral Health Treatment for Pervasive Developmental Disorder or Autism

• Chemical Dependency Services

• Dental and Orthodontic Services

• Dialysis Care

• Durable Medical Equipment for Home Use

• Family Planning Services

• Health Education

• Hearing Services

• Home Health Care

• Hospice Care

• Infertility Services

• Mental Health Services

• Ostomy and Urological Supplies

• Outpatient Imaging, Laboratory, and Special Procedures

• Outpatient Prescription Drugs, Supplies, and Supplements

• Prosthetic and Orthotic Devices

• Reconstructive Surgery


• Rehabilitative and Habilitative Services

• Services in Connection with a Clinical Trial

• Transplant Services

• Vision Services

Hospital Inpatient Care We cover the following inpatient Services at a $250 Copayment per day up to a maximum of $1,250 per admission in a Plan Hospital, when the Services are generally and customarily provided by acute care general hospitals inside your Home Region Service Area:

• Room and board, including a private room if Medically Necessary

• Specialized care and critical care units

• General and special nursing care

• Operating and recovery rooms

• Services of Plan Physicians, including consultation and treatment by specialists

• Anesthesia

• Drugs prescribed in accord with our drug formulary guidelines (for discharge drugs prescribed when you are released from the hospital, please refer to "Outpatient Prescription Drugs, Supplies, and Supplements" in this "Benefits and Your Cost Share" section)

• Radioactive materials used for therapeutic purposes

• Durable medical equipment and medical supplies

• Imaging, laboratory, and special procedures, including MRI, CT, and PET scans

• Blood, blood products, and their administration

• Obstetrical care and delivery (including cesarean section). Note: If you are discharged within 48 hours after delivery (or within 96 hours if delivery is by cesarean section), your Plan Physician may order a follow-up visit for you and your newborn to take place within 48 hours after discharge (for visits after you are released from the hospital, please refer to "Outpatient Care" in this "Benefits and Your Cost Share" section)

• Behavioral health treatment for pervasive developmental disorder or autism

• Respiratory therapy

• Medical social services and discharge planning

Coverage for Services related to "Hospital Inpatient Care" described in other sections The following types of inpatient Services are covered only as described under the following headings in this "Benefits and Your Cost Share" section:

• Bariatric Surgery

• Chemical Dependency Services

• Dental and Orthodontic Services

• Dialysis Care

• Hospice Care

• Infertility Services

• Mental Health Services • Prosthetic and Orthotic Devices

• Reconstructive Surgery

• Rehabilitative and Habilitative Services

• Services in Connection with a Clinical Trial

• Skilled Nursing Facility Care

• Transplant Services

Ambulance Services Emergency We cover at a $150 Copayment per trip Services of a licensed ambulance anywhere in the world without prior authorization (including transportation through the 911 emergency response system where available) in the following situations: • A reasonable person would have believed that the

medical condition was an Emergency Medical Condition which required ambulance Services

• Your treating physician determines that you must be transported to another facility because your Emergency Medical Condition is not Stabilized and the care you need is not available at the treating facility

If you receive emergency ambulance Services that are not ordered by a Plan Provider, you are not responsible for any amounts beyond your Cost Share for covered emergency ambulance Services. However, if the provider does not agree to bill us, you may have to pay for the Services and file a claim for reimbursement. For information on how to file a claim, please see the "Post-Service Claims and Appeals" section.

Nonemergency Inside your Home Region Service Area, we cover nonemergency ambulance and psychiatric transport van Services at a $150 Copayment per trip if a Plan


Physician determines that your condition requires the use of Services that only a licensed ambulance (or psychiatric transport van) can provide and that the use of other means of transportation would endanger your health. These Services are covered only when the vehicle transports you to or from covered Services.

Ambulance Services exclusion • Transportation by car, taxi, bus, gurney van,

wheelchair van, and any other type of transportation (other than a licensed ambulance or psychiatric transport van), even if it is the only way to travel to a Plan Provider

Bariatric Surgery We cover hospital inpatient care related to bariatric surgical procedures (including room and board, imaging, laboratory, special procedures, and Plan Physician Services) when performed to treat obesity by modification of the gastrointestinal tract to reduce nutrient intake and absorption, if all of the following requirements are met:

• You complete the Medical Group–approved pre-surgical educational preparatory program regarding lifestyle changes necessary for long term bariatric surgery success

• A Plan Physician who is a specialist in bariatric care determines that the surgery is Medically Necessary

For covered Services related to bariatric surgical procedures that you receive, you will pay the Cost Share you would pay if the Services were not related to a bariatric surgical procedure. For example, see "Hospital Inpatient Care" in this "Benefits and Your Cost Share" section for the Cost Share that applies for hospital inpatient care.

If you live 50 miles or more from the facility to which you are referred for a covered bariatric surgery, we will reimburse you for certain travel and lodging expenses if you receive prior written authorization from the Medical Group and send us adequate documentation including receipts. We will not, however, reimburse you for any travel or lodging expenses if you were offered a referral to a facility that is less than 50 miles from your home. We will reimburse authorized and documented travel and lodging expenses as follows: • Transportation for you to and from the facility up to

$130 per round trip for a maximum of three trips (one pre-surgical visit, the surgery, and one follow-up visit), including any trips for which we provided reimbursement under any other evidence of coverage

• Transportation for one companion to and from the facility up to $130 per round trip for a maximum of two trips (the surgery and one follow-up visit), including any trips for which we provided reimbursement under any other evidence of coverage

• One hotel room, double-occupancy, for you and one companion not to exceed $100 per day for the pre-surgical visit and the follow-up visit, up to two days per trip, including any hotel accommodations for which we provided reimbursement under any other evidence of coverage

• Hotel accommodations for one companion not to exceed $100 per day for the duration of your surgery stay, up to four days, including any hotel accommodations for which we provided reimbursement under any other evidence of coverage

Coverage for Services related to "Bariatric Surgery" described in other sections Coverage for the following Services is described under these headings in this "Benefits and Your Cost Share" section: • Outpatient prescription drugs (refer to "Outpatient

Prescription Drugs, Supplies, and Supplements") • Outpatient administered drugs (refer to "Outpatient

Care")

Behavioral Health Treatment for Pervasive Developmental Disorder or Autism The following terms have special meaning when capitalized and used in this "Behavioral Health Treatment for Pervasive Developmental Disorder or Autism" section:

• "Qualified Autism Service Provider" means a provider who has the experience and competence to design, supervise, provide, or administer treatment for pervasive developmental disorder or autism and is either of the following: ♦ a person, entity, or group that is certified by a

national entity (such as the Behavior Analyst Certification Board) that is accredited by the National Commission for Certifying Agencies

♦ a person licensed in California as a physician, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist


• "Qualified Autism Service Professional" means a person who meets all of the following criteria: ♦ provides behavioral health treatment ♦ is employed and supervised by a Qualified Autism

Service Provider ♦ provides treatment pursuant to a treatment plan

developed and approved by the Qualified Autism Service Provider

♦ is a behavioral health treatment provider approved as a vendor by a California regional center to provide Services as an Associate Behavior Analyst, Behavior Analyst, Behavior Management Assistant, Behavior Management Consultant, or Behavior Management Program as defined in Section 54342 of Title 17 of the California Code of Regulations

♦ has training and experience in providing Services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code

• "Qualified Autism Service Paraprofessional" means an unlicensed and uncertified individual who meets all of the following criteria: ♦ is employed and supervised by a Qualified Autism

Service Provider ♦ provides treatment and implements Services

pursuant to a treatment plan developed and approved by the Qualified Autism Service Provider

♦ meets the criteria set forth in the regulations adopted pursuant to Section 4686.3 of the Welfare and Institutions Code

♦ has adequate education, training, and experience, as certified by a Qualified Autism Service Provider

We cover behavioral health treatment for pervasive developmental disorder or autism (including applied behavior analysis and evidence-based behavior intervention programs) that develops or restores, to the maximum extent practicable, the functioning of a person with pervasive developmental disorder or autism and that meet all of the following criteria: • The Services are provided inside your Home Region

Service Area • The treatment is prescribed by a Plan Physician, or is

developed by a Plan Provider who is a psychologist • The treatment is provided under a treatment plan

prescribed by a Plan Provider who is a Qualified Autism Service Provider

• The treatment is administered by a Plan Provider who is one of the following: ♦ a Qualified Autism Service Provider ♦ a Qualified Autism Service Professional

supervised and employed by the Qualified Autism Service Provider

♦ a Qualified Autism Service Paraprofessional supervised and employed by a Qualified Autism Service Provider

• The treatment plan has measurable goals over a specific timeline that is developed and approved by the Qualified Autism Service Provider for the Member being treated

• The treatment plan is reviewed no less than once every six months by the Qualified Autism Service Provider and modified whenever appropriate

• The treatment plan requires the Qualified Autism Service Provider to do all of the following: ♦ Describe the Member's behavioral health

impairments to be treated ♦ Design an intervention plan that includes the

service type, number of hours, and parent participation needed to achieve the plan's goal and objectives, and the frequency at which the Member's progress is evaluated and reported

♦ Provide intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism

♦ Discontinue intensive behavioral intervention Services when the treatment goals and objectives are achieved or no longer appropriate

• The treatment plan is not used for either of the following: ♦ for purposes of providing (or for the

reimbursement of) respite care, day care, or educational services

♦ to reimburse a parent for participating in the treatment program

You pay the following for these covered Services:

• Individual visits: a $20 Copayment per visit

• Group visits: a $10 Copayment per visit

Effective as of the date that federal proposed final rulemaking for essential health benefits is issued, we will cover Services under this "Behavioral Health Treatment for Pervasive Developmental Disorder or Autism" section only if they are included in the essential health benefits that all health plans will be required by federal regulations to provide under section 1302(b) of the


federal Patient Protection and Affordable Care Act, as amended by the federal Health Care and Education Reconciliation Act.

Chemical Dependency Services Inpatient detoxification We cover hospitalization at a $250 Copayment per day up to a maximum of $1,250 per admission in a Plan Hospital only for medical management of withdrawal symptoms, including room and board, Plan Physician Services, drugs, dependency recovery Services, education, and counseling.

Outpatient chemical dependency care We cover the following Services for treatment of chemical dependency: • Day-treatment programs

• Intensive outpatient programs

• Individual and group chemical dependency counseling

• Medical treatment for withdrawal symptoms

You pay the following for these covered Services: • Individual chemical dependency evaluation and

treatment: a $20 Copayment per visit • Group chemical dependency treatment: a

$5 Copayment per visit

Transitional residential recovery Services We cover chemical dependency treatment in a nonmedical transitional residential recovery setting approved in writing by the Medical Group. We cover these Services at a $100 Copayment per admission. These settings provide counseling and support services in a structured environment.

Residential rehabilitation Services in a residential rehabilitation program setting are not covered.

Coverage for Services related to "Chemical Dependency Services" described in other sections Coverage for the following Services is described under these headings in this "Benefits and Your Cost Share" section: • Outpatient laboratory (refer to "Outpatient Imaging,

Laboratory, and Special Procedures") • Outpatient self-administered drugs (refer to

"Outpatient Prescription Drugs, Supplies, and Supplements")

Chemical dependency Services exclusion • Services in a specialized facility for alcoholism, drug

abuse, or drug addiction except as otherwise described in this "Chemical Dependency Services" section

Dental and Orthodontic Services We do not cover most dental and orthodontic Services, but we do cover some dental and orthodontic Services as described in this "Dental and Orthodontic Services" section.

Dental Services for radiation treatment We cover dental evaluation, X-rays, fluoride treatment, and extractions necessary to prepare your jaw for radiation therapy of cancer in your head or neck if a Plan Physician provides the Services or if the Medical Group authorizes a referral to a dentist (as described in "Medical Group authorization procedure for certain referrals" under "Getting a Referral" in the "How to Obtain Services" section).

Dental anesthesia For dental procedures at a Plan Facility, we provide general anesthesia and the facility's Services associated with the anesthesia if all of the following are true:

• You are under age 7, or you are developmentally disabled, or your health is compromised

• Your clinical status or underlying medical condition requires that the dental procedure be provided in a hospital or outpatient surgery center

• The dental procedure would not ordinarily require general anesthesia

We do not cover any other Services related to the dental procedure, such as the dentist's Services.

Accidental injury to teeth Services for accidental injury to teeth are not covered.

Dental and orthodontic Services for cleft palate We cover dental extractions, dental procedures necessary to prepare the mouth for an extraction, and orthodontic Services, if they meet all of the following requirements: • The Services are an integral part of a reconstructive

surgery for cleft palate that we are covering under "Reconstructive Surgery" in this "Benefits and Your Cost Share" section ("cleft palate" includes cleft palate, cleft lip, or other craniofacial anomalies associated with cleft palate)

• A Plan Provider provides the Services or the Medical Group authorizes a referral to a Non–Plan Provider


who is a dentist or orthodontist (as described in "Medical Group authorization procedure for certain referrals" under "Getting a Referral" in the "How to Obtain Services" section)

Your Cost Share for dental and orthodontic Services You pay the following for dental and orthodontic Services covered under this "Dental and Orthodontic Services" section: • Hospital inpatient care (including room and board,

drugs, imaging, laboratory, special procedures, and Plan Physician Services): a $250 Copayment per day up to a maximum of $1,250 per admission

• Primary Care Visits for evaluations and treatment: a $20 Copayment per visit

• Specialty Care Visits for consultations, evaluations, and treatment: a $40 Copayment per visit




Coverage for Services related to "Dental and Orthodontic Services" described in other sections Coverage for the following Services is described under these headings in this "Benefits and Your Cost Share" section: • Outpatient imaging, laboratory, and special

procedures (refer to "Outpatient Imaging, Laboratory, and Special Procedures")

• Outpatient administered drugs (refer to "Outpatient Care"), except that we cover outpatient administered drugs under "Dental anesthesia" in this "Dental and Orthodontic Services" section

• Outpatient prescription drugs (refer to "Outpatient Prescription Drugs, Supplies, and Supplements")

Dialysis Care We cover acute and chronic dialysis Services if all of the following requirements are met: • The Services are provided inside your Home Region

Service Area

• You satisfy all medical criteria developed by the Medical Group and by the facility providing the dialysis

• A Plan Physician provides a written referral for care at the facility

After you receive appropriate training at a dialysis facility we designate, we also cover equipment and medical supplies required for home hemodialysis and home peritoneal dialysis inside your Home Region Service Area at no charge. Coverage is limited to the standard item of equipment or supplies that adequately meets your medical needs. We decide whether to rent or purchase the equipment and supplies, and we select the vendor. You must return the equipment and any unused supplies to us or pay us the fair market price of the equipment and any unused supply when we are no longer covering them.

You pay the following for these covered Services related to dialysis: • Inpatient dialysis care: a $250 Copayment per day

up to a maximum of $1,250 per admission • One routine outpatient visit per month with the

multidisciplinary nephrology team for a consultation, evaluation, or treatment: no charge

• Hemodialysis treatment at a Plan Facility: a $40 Copayment per visit

• All other Primary Care Visits for evaluations and treatment: a $20 Copayment per visit

• All other Specialty Care Visits for consultations, evaluations, and treatment: a $40 Copayment per visit

Coverage for Services related to "Dialysis Care" described in other sections Coverage for the following Services is described under these headings in this "Benefits and Your Cost Share" section:

• Durable medical equipment for home use (refer to "Durable Medical Equipment for Home Use")


• Outpatient laboratory (refer to "Outpatient Imaging, Laboratory, and Special Procedures")


• Outpatient administered drugs (refer to "Outpatient Care")

Dialysis Care exclusions • Comfort, convenience, or luxury equipment, supplies

and features

• Nonmedical items, such as generators or accessories to make home dialysis equipment portable for travel

Durable Medical Equipment for Home Use Inside your Home Region Service Area, we cover the durable medical equipment specified in this "Durable Medical Equipment for Home Use" section for use in your home (or another location used as your home) in accord with our durable medical equipment formulary guidelines. Durable medical equipment for home use is an item that is intended for repeated use, primarily and customarily used to serve a medical purpose, generally not useful to a person who is not ill or injured, and appropriate for use in the home.

Coverage is limited to the standard item of equipment that adequately meets your medical needs. We decide whether to rent or purchase the equipment, and we select the vendor. You must return the equipment to us or pay us the fair market price of the equipment when we are no longer covering it.

Durable medical equipment items that are essential health benefits Inside your Home Region Service Area, we cover the following durable medical equipment (including repair or replacement of covered equipment) at 10% Coinsurance:

• Blood glucose monitors for diabetes blood testing and their supplies (such as blood glucose monitor test strips, lancets, and lancet devices)

• Bone stimulator

• Canes (standard curved handle or quad) and replacement supplies

• Cervical traction (over door) • Crutches (standard or forearm) and replacement

supplies

• Dry pressure pad for a mattress

• Enteral pump and supplies

• Infusion pumps (such as insulin pumps) and supplies to operate the pump

• IV pole

• Nebulizer and supplies

• Peak flow meters

• Phototherapy blankets for treatment of jaundice in newborns

• Tracheostomy tube and supplies

Breastfeeding supplies We will cover at no charge one retail-grade breast pump per pregnancy and the necessary supplies to operate it, such as one set of bottles. We will decide whether to rent or purchase the item and we choose the vendor. We cover this pump for convenience purposes. The pump is not subject to prior authorization requirements or the formulary guidelines.

Inside your Home Region Service Area, if you or your baby has a medical condition that requires the use of a breast pump, we will cover at no charge a hospital-grade breast pump and the necessary supplies to operate it, in accord with our durable medical equipment formulary guidelines. We will determine whether to rent or purchase the equipment and we choose the vendor. Hospital-grade breast pumps on our formulary are subject to the durable medical equipment prior authorization requirements as described in "Medical Group authorization procedure for certain referrals" under "Getting a Referral" in the "How to Obtain Services" section. For more information about our durable medical equipment formulary, see the "About our durable medical equipment formulary" in this "Durable Medical Equipment for Home Use" section.

Durable medical equipment items that are not essential health benefits Durable medical equipment that are not essential health benefits are not covered.

Outside your Home Region Service Area We do not cover most durable medical equipment for home use outside your Home Region Service Area. However, if you live outside your Home Region Service Area, we cover the following durable medical equipment (subject to the Cost Share and all other coverage requirements that apply to durable medical equipment for home use inside your Home Region Service Area) when the item is dispensed at a Plan Facility: • Blood glucose monitors for diabetes blood testing and

their supplies (such as blood glucose monitor test strips, lancets, and lancet devices) from a Plan Pharmacy


• Canes (standard curved handle)

• Crutches (standard)

• Insulin pumps and supplies to operate the pump, after completion of training and education on the use of the pump

• Nebulizers and their supplies for the treatment of pediatric asthma

• Peak flow meters from a Plan Pharmacy

About our durable medical equipment formulary Our durable medical equipment formulary includes the list of durable medical equipment that has been approved by our Durable Medical Equipment Formulary Executive Committee for our Members. Our durable medical equipment formulary was developed by a multidisciplinary clinical and operational work group with review and input from Plan Physicians and medical professionals with durable medical equipment expertise (for example: physical, respiratory, and enterostomal therapists and home health). A multidisciplinary Durable Medical Equipment Formulary Executive Committee is responsible for reviewing and revising the durable medical equipment formulary. Our durable medical equipment formulary is periodically updated to keep pace with changes in medical technology and clinical practice. To find out whether a particular item is included in our durable medical equipment formulary, please call our Member Service Contact Center.

Our formulary guidelines allow you to obtain nonformulary durable medical equipment (equipment not listed on our durable medical equipment formulary for your condition) if the equipment would otherwise be covered and the Medical Group determines that it is Medically Necessary as described in "Medical Group authorization procedure for certain referrals" under "Getting a Referral" in the "How to Obtain Services" section.

Coverage for Services related to "Durable Medical Equipment for Home Use" described in other sections Coverage for the following Services is described under these headings in this "Benefits and Your Cost Share" section: • Dialysis equipment and supplies required for home

hemodialysis and home peritoneal dialysis (refer to "Dialysis Care")

• Diabetes urine testing supplies and insulin-administration devices other than insulin pumps (refer to "Outpatient Prescription Drugs, Supplies, and Supplements")

• Durable medical equipment related to the terminal illness for Members who are receiving covered hospice care (refer to "Hospice Care")

• Insulin and any other drugs administered with an infusion pump (refer to "Outpatient Prescription Drugs, Supplies, and Supplements")

Durable medical equipment for home use exclusions • Comfort, convenience, or luxury equipment or

features except for retail-grade breast pumps as described under "Breastfeeding supplies" in this "Durable Medical Equipment for Home Use" section

• Repair or replacement of equipment due to loss or misuse

Family Planning Services We cover the following family planning Services subject to the Cost Share indicated: • Family planning counseling: no charge

• Consultations for internally implanted time-release contraceptives or intrauterine devices (IUDs): no charge

• Female sterilization procedures if provided in an outpatient or ambulatory surgery center or in a hospital operating room: no charge

• All other female sterilization procedures: no charge

• Male sterilization procedures if provided in an outpatient or ambulatory surgery center or in a hospital operating room: a $250 Copayment per procedure

• All other male sterilization procedures: a $40 Copayment per visit

• Termination of pregnancy: a $40 Copayment per procedure

Coverage for Services related to "Family Planning Services" described in other sections Coverage for the following Services is described under these headings in this "Benefits and Your Cost Share" section: • Services to diagnose or treat infertility (refer to

"Infertility Services") • Outpatient laboratory and imaging services associated

with family planning services (refer to "Outpatient Imaging, Laboratory, and Special Procedures")

• Outpatient contraceptive drugs and devices (refer to "Outpatient Prescription Drugs, Supplies, and Supplements")


Family Planning Services exclusions • Reversal of voluntary sterilization

Health Education We cover a variety of health education counseling, programs, and materials that your personal Plan Physician or other Plan Providers provide during a visit covered under another part of this "Benefits and Your Cost Share" section.

We also cover a variety of health education counseling, programs, and materials to help you take an active role in protecting and improving your health, including programs for tobacco cessation, stress management, and chronic conditions (such as diabetes and asthma). Kaiser Permanente also offers health education counseling, programs, and materials that are not covered, and you may be required to pay a fee.

For more information about our health education counseling, programs, and materials, please contact a Health Education Department or our Member Service Contact Center, refer to Your Guidebook, or go to our website at kp.org.


• Covered health education programs, which may include programs provided online and counseling over the phone: no charge

• Individual counseling during an office visit related to smoking cessation: no charge

• Individual counseling during an office visit related to diabetes management: no charge

• Other covered individual counseling when the office visit is solely for health education: no charge

• Health education provided during an outpatient consultation or evaluation covered in another part of this "Benefits and Your Cost Share" section: no additional Cost Share beyond the Cost Share required in that other part of this "Benefits and Your Cost Share" section

• Covered health education materials: no charge

Hearing Services We do not cover hearing aids (other than internally-implanted devices as described in the "Prosthetic and Orthotic Devices" section). However, we do cover hearing exams to determine the need for hearing correction at no charge.

Coverage for Services related to "Hearing Services" described in other sections Coverage for the following Services is described under these headings in this "Benefits and Your Cost Share" section:

• Routine hearing screenings when performed as part of a routine physical maintenance exam (refer to "Outpatient Care")

• Services related to the ear or hearing other than those described in this section, such as outpatient care to treat an ear infection and outpatient prescription drugs, supplies, and supplements (refer to the applicable heading in this "Benefits and Your Cost Share" section)

• Cochlear implants and osseointegrated hearing devices (refer to "Prosthetic and Orthotic Devices")

Hearing Services exclusions • Hearing aids and tests to determine their efficacy, and

hearing tests to determine an appropriate hearing aid

Home Health Care "Home health care" means Services provided in the home by nurses, medical social workers, home health aides, and physical, occupational, and speech therapists. We cover home health care at no charge only if all of the following are true: • You are substantially confined to your home (or a

friend's or relative's home)

• Your condition requires the Services of a nurse, physical therapist, occupational therapist, or speech therapist (home health aide Services are not covered unless you are also getting covered home health care from a nurse, physical therapist, occupational therapist, or speech therapist that only a licensed provider can provide)

• A Plan Physician determines that it is feasible to maintain effective supervision and control of your care in your home and that the Services can be safely and effectively provided in your home

• The Services are provided inside your Home Region Service Area

We cover only part-time or intermittent home health care, as follows: • Up to two hours per visit for visits by a nurse,

medical social worker, or physical, occupational, or speech therapist, and up to four hours per visit for visits by a home health aide


• Up to three visits per day (counting all home health visits)

• Up to 100 visits per calendar year (counting all home health visits)

Note: If a visit by a nurse, medical social worker, or physical, occupational, or speech therapist lasts longer than two hours, then each additional increment of two hours counts as a separate visit. If a visit by a home health aide lasts longer than four hours, then each additional increment of four hours counts as a separate visit. For example, if a nurse comes to your home for three hours and then leaves, that counts as two visits. Also, each person providing Services counts toward these visit limits. For example, if a home health aide and a nurse are both at your home during the same two hours, that counts as two visits.

Coverage for Services related to "Home Health Care" described in other sections Coverage for the following Services is described under these headings in this "Benefits and Your Cost Share" section: • Behavioral health treatment for pervasive

developmental disorder or autism (refer to "Behavioral Health Treatment for Pervasive Developmental Disorder or Autism")

• Dialysis care (refer to "Dialysis Care")

• Durable medical equipment (refer to "Durable Medical Equipment for Home Use")

• Ostomy and urological supplies (refer to "Ostomy and Urological Supplies")

• Outpatient drugs, supplies, and supplements (refer to "Outpatient Prescription Drugs, Supplies, and Supplements")

• Prosthetic and orthotic devices (refer to "Prosthetic and Orthotic Devices")

Home health care exclusions • Care of a type that an unlicensed family member or

other layperson could provide safely and effectively in the home setting after receiving appropriate training. This care is excluded even if we would cover the care if it were provided by a qualified medical professional in a hospital or a Skilled Nursing Facility

• Care in the home if the home is not a safe and effective treatment setting

Hospice Care Hospice care is a specialized form of interdisciplinary health care designed to provide palliative care and to alleviate the physical, emotional, and spiritual discomforts of a Member experiencing the last phases of life due to a terminal illness. It also provides support to the primary caregiver and the Member's family. A Member who chooses hospice care is choosing to receive palliative care for pain and other symptoms associated with the terminal illness, but not to receive care to try to cure the terminal illness. You may change your decision to receive hospice care benefits at any time.

We cover the hospice Services listed below at no charge only if all of the following requirements are met: • A Plan Physician has diagnosed you with a terminal

illness and determines that your life expectancy is 12 months or less

• The Services are provided inside your Home Region Service Area or inside California but within 15 miles or 30 minutes from your Home Region Service Area (including a friend's or relative's home even if you live there temporarily)

• The Services are provided by a licensed hospice agency that is a Plan Provider

• The Services are necessary for the palliation and management of your terminal illness and related conditions

If all of the above requirements are met, we cover the following hospice Services, which are available on a 24-hour basis if necessary for your hospice care:

• Plan Physician Services

• Skilled nursing care, including assessment, evaluation, and case management of nursing needs, treatment for pain and symptom control, provision of emotional support to you and your family, and instruction to caregivers

• Physical, occupational, or speech therapy for purposes of symptom control or to enable you to maintain activities of daily living


• Medical social services

• Home health aide and homemaker services

• Palliative drugs prescribed for pain control and symptom management of the terminal illness for up to a 100-day supply in accord with our drug formulary guidelines. You must obtain these drugs from a Plan Pharmacy. Certain drugs are limited to a maximum 30-day supply in any 30-day period (please


call our Member Service Contact Center for the current list of these drugs)

• Durable medical equipment

• Respite care when necessary to relieve your caregivers. Respite care is occasional short-term inpatient care limited to no more than five consecutive days at a time

• Counseling and bereavement services

• Dietary counseling

• The following care during periods of crisis when you need continuous care to achieve palliation or management of acute medical symptoms: ♦ nursing care on a continuous basis for as much as

24 hours a day as necessary to maintain you at home

♦ short-term inpatient care required at a level that cannot be provided at home

Infertility Services Services for diagnosis and treatment of infertility are not covered. For purposes of this "Infertility Services" section, "infertility" means not being able get pregnant or carry a pregnancy to a live birth after a year or more of regular sexual relations without contraception or having a medical or other demonstrated condition that is recognized by a Plan Physician as a cause of infertility.

Coverage and your Cost Share for Infertility Services You pay the following for these Services related to infertility:

Service

Your Cost Share Diagnosis,

Treatment and Artificial

Insemination

GIFT, ZIFT, or IVF Services

Specialty Care Visits Not covered Not covered

Outpatient surgery and outpatient procedures

Not covered Not covered

Outpatient imaging Not covered Not covered Outpatient laboratory Not covered Not covered

Outpatient special procedures Not covered Not covered

Outpatient administered drugs Not covered Not covered

Hospital inpatient care Not covered Not covered

Coverage for Services related to "Infertility Services" described in other sections Coverage for the following Services is described under these headings in this "Benefits and Your Cost Share" section:

• Outpatient drugs, supplies, and supplements (refer to "Outpatient Prescription Drugs, Supplies, and Supplements")

Infertility Services exclusions • Services to diagnose or treat infertility

• Services to reverse voluntary, surgically induced infertility

• Semen and eggs (and Services related to their procurement and storage)

• Conception by artificial means, such as ovum transplants, gamete intrafallopian transfer (GIFT), semen and eggs (and Services related to their procurement and storage), in vitro fertilization (IVF), and zygote intrafallopian transfer (ZIFT).

Mental Health Services We cover Services specified in this "Mental Health Services" section only when the Services are for the diagnosis or treatment of Mental Disorders. A "Mental Disorder" is a mental health condition identified as a "mental disorder" in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM) that results in clinically significant distress or impairment of mental, emotional, or behavioral functioning. We do not cover services for conditions that the DSM identifies as something other than a "mental disorder." For example, the DSM identifies relational problems as something other than a "mental disorder," so we do not cover services (such as couples counseling or family counseling) for relational problems.

"Mental Disorders" include the following conditions: • Severe Mental Illness of a person of any age. "Severe

Mental Illness" means the following mental disorders: schizophrenia, schizoaffective disorder, bipolar disorder (manic-depressive illness), major depressive disorders, panic disorder, obsessive-compulsive disorder, pervasive developmental disorder or autism, anorexia nervosa, or bulimia nervosa

• A Serious Emotional Disturbance of a child under age 18. A "Serious Emotional Disturbance" of a child under age 18 means a condition identified as a "mental disorder" in the DSM, other than a primary substance use disorder or developmental disorder,


that results in behavior inappropriate to the child's age according to expected developmental norms, if the child also meets at least one of the following three criteria: ♦ as a result of the mental disorder, (1) the child has

substantial impairment in at least two of the following areas: self-care, school functioning, family relationships, or ability to function in the community; and (2) either (a) the child is at risk of removal from the home or has already been removed from the home, or (b) the mental disorder and impairments have been present for more than six months or are likely to continue for more than one year without treatment

♦ the child displays psychotic features, or risk of suicide or violence due to a mental disorder

♦ the child meets special education eligibility requirements under Chapter 26.5 (commencing with Section 7570) of Division 7 of Title 1 of the California Government Code

Outpatient mental health Services We cover the following Services when provided by Plan Physicians or other Plan Providers who are licensed health care professionals acting within the scope of their license: • Individual and group mental health evaluation and

treatment

• Psychological testing when necessary to evaluate a Mental Disorder

• Outpatient Services for the purpose of monitoring drug therapy


• Individual mental health evaluation and treatment: a $20 Copayment per visit

• Group mental health treatment: a $10 Copayment per visit

Note: Outpatient intensive psychiatric treatment programs are not covered under this "Outpatient mental health Services" section (refer to "Intensive psychiatric treatment programs" under "Inpatient psychiatric hospitalization and intensive psychiatric treatment programs" in this "Mental Health Services" section).

Inpatient psychiatric hospitalization and intensive psychiatric treatment programs Inpatient psychiatric hospitalization. We cover inpatient psychiatric hospitalization in a Plan Hospital. Coverage includes room and board, drugs, and Services of Plan Physicians and other Plan Providers who are

licensed health care professionals acting within the scope of their license. We cover these Services at a $250 Copayment per day up to a maximum of $1,250 per admission.

Intensive psychiatric treatment programs. We cover at no charge the following intensive psychiatric treatment programs at a Plan Facility: • Short-term hospital-based intensive outpatient care

(partial hospitalization)

• Short-term multidisciplinary treatment in an intensive outpatient psychiatric treatment program

• Short-term treatment in a crisis residential program in licensed psychiatric treatment facility with 24-hour-a-day monitoring by clinical staff for stabilization of an acute psychiatric crisis

• Psychiatric observation for an acute psychiatric crisis

Coverage for Services related to "Mental Health Services" described in other sections Coverage for the following Services is described under these headings in this "Benefits and Your Cost Share" section: • Outpatient drugs, supplies, and supplements (refer to

"Outpatient Prescription Drugs, Supplies, and Supplements")

• Outpatient laboratory (refer to "Outpatient Imaging, Laboratory, and Special Procedures")

Ostomy and Urological Supplies We cover ostomy and urological supplies prescribed in accord with our soft goods formulary guidelines at no charge. We select the vendor, and coverage is limited to the standard supply that adequately meets your medical needs.

About our soft goods formulary Our soft goods formulary includes the list of ostomy and urological supplies that have been approved by our Soft Goods Formulary Executive Committee for our Members. Our Soft Goods Formulary Executive Committee is responsible for reviewing and revising the soft goods formulary. Our soft goods formulary is periodically updated to keep pace with changes in medical technology and clinical practice. To find out whether a particular ostomy or urological supply is included in our soft goods formulary, please call our Member Service Contact Center.

Our formulary guidelines allow you to obtain nonformulary ostomy and urological supplies (those not listed on our soft goods formulary for your condition)


if they would otherwise be covered and the Medical Group determines that they are Medically Necessary as described in "Medical Group authorization procedure for certain referrals" under "Getting a Referral" in the "How to Obtain Services" section.

Ostomy and urological supplies exclusion • Comfort, convenience, or luxury equipment or

features

Outpatient Imaging, Laboratory, and Special Procedures We cover the following Services at the Cost Share indicated only when prescribed as part of care covered under other headings in this "Benefits and Your Cost Share" section:

• Imaging Services that are Preventive Care Services: ♦ screening mammograms: no charge ♦ screening ultrasounds for abdominal aortic

aneurysm: no charge ♦ screening CT scans for lung cancer: no charge ♦ bone density CT scans: no charge ♦ bone density DEXA scans: no charge

• All other CT scans, and all MRIs and PET scans: a $150 Copayment per procedure

• All other imaging Services, such as diagnostic and therapeutic X-rays, mammograms, and ultrasounds: a $40 Copayment per encounter except that certain imaging procedures are covered at a $250 Copayment per procedure if they are provided in an outpatient or ambulatory surgery center or in a hospital operating room, or if they are provided in any setting and a licensed staff member monitors your vital signs as you regain sensation after receiving drugs to reduce sensation or to minimize discomfort

• Nuclear medicine: a $40 Copayment per encounter

• Laboratory tests and screenings that are Preventive Care Services: ♦ fecal occult blood tests: no charge ♦ routine laboratory tests and screenings, such as

cervical cancer screenings, prostate specific antigen tests, cholesterol tests (lipid panel and profile), fasting blood glucose tests, glucose tolerance tests, sexually transmitted disease (STD) tests, genetic testing for breast cancer susceptibility, and HIV tests: no charge

♦ routine retinal photography screenings: no charge

• Laboratory tests to monitor the effectiveness of dialysis: no charge

• All other laboratory tests (including tests for specific genetic disorders for which genetic counseling is available): a $20 Copayment per encounter

• All other diagnostic procedures provided by Plan Providers who are not physicians (such as EKGs and EEGs): a $40 Copayment per encounter except that certain diagnostic procedures are covered at a $250 Copayment per procedure if they are provided in an outpatient or ambulatory surgery center or in a hospital operating room, or if they are provided in any setting and a licensed staff member monitors your vital signs as you regain sensation after receiving drugs to reduce sensation or to minimize discomfort

• Radiation therapy: no charge

• Ultraviolet light treatments: no charge

Coverage for Services related to "Outpatient Imaging, Laboratory, and Special Procedures" described in other sections Coverage for the following Services is described under these headings in this "Benefits and Your Cost Share" section: • Services related to diagnosis and treatment of

infertility (refer to "Infertility Services")

Outpatient Prescription Drugs, Supplies, and Supplements We cover outpatient drugs, supplies, and supplements specified in this "Outpatient Prescription Drugs, Supplies, and Supplements" section when prescribed as follows and obtained at a Plan Pharmacy or through our mail-order service: • Items prescribed by Plan Physicians in accord with

our drug formulary guidelines

• Items prescribed by the following Non–Plan Providers unless a Plan Physician determines that the item is not Medically Necessary or the drug is for a sexual dysfunction disorder: ♦ Dentists if the drug is for dental care ♦ Non–Plan Physicians if the Medical Group

authorizes a written referral to the Non–Plan Physician (in accord with "Medical Group authorization procedure for certain referrals" under "Getting a Referral" in the "How to Obtain Services" section) and the drug, supply, or supplement is covered as part of that referral

♦ Non–Plan Physicians if the prescription was obtained as part of covered Emergency Services,


Post-Stabilization Care, or Out-of-Area Urgent Care described in the "Emergency Services and Urgent Care" section (if you fill the prescription at a Plan Pharmacy, you may have to pay Charges for the item and file a claim for reimbursement as described under "Payment and Reimbursement" in the "Emergency Services and Urgent Care" section)

How to obtain covered items You must obtain covered items at a Plan Pharmacy or through our mail-order service unless you obtain the item as part of covered Emergency Services, Post-Stabilization Care, or Out-of-Area Urgent Care described in the "Emergency Services and Urgent Care" section.

Please refer to Your Guidebook for the locations of Plan Pharmacies in your area.

Refills. You may be able to order refills at a Plan Pharmacy, through our mail-order service, or through our website at kp.org/rxrefill. A Plan Pharmacy or Your Guidebook can give you more information about obtaining refills, including the options available to you for obtaining refills. For example, a few Plan Pharmacies don't dispense refills and not all drugs can be mailed through our mail-order service. Please check with a Plan Pharmacy if you have a question about whether your prescription can be mailed or obtained at a Plan Pharmacy. Items available through our mail-order service are subject to change at any time without notice.

Day supply limit The prescribing physician or dentist determines how much of a drug, supply, or supplement to prescribe. For purposes of day supply coverage limits, Plan Physicians determine the amount of an item that constitutes a Medically Necessary 30- or 100-day supply for you. Upon payment of the Cost Share specified in this "Outpatient Prescription Drugs, Supplies, and Supplements" section, you will receive the supply prescribed up to the day supply limit also specified in this section. The day supply limit is either one 30-day supply in a 30-day period or one 100-day supply in a 100-day period. If you wish to receive more than the covered day supply limit, then you must pay Charges for any prescribed quantities that exceed the day supply limit. Note: We cover episodic drugs prescribed for the treatment of sexual dysfunction disorders up to a maximum of 8 doses in any 30-day period or up to 27 doses in any 100-day period.

The pharmacy may reduce the day supply dispensed at the Cost Share specified in this "Outpatient Prescription Drugs, Supplies, and Supplements" section to a 30-day supply in any 30-day period if the pharmacy determines

that the item is in limited supply in the market or for specific drugs (your Plan Pharmacy can tell you if a drug you take is one of these drugs).

About our drug formulary Our drug formulary includes the list of drugs that our Pharmacy and Therapeutics Committee has approved for our Members. Our Pharmacy and Therapeutics Committee, which is primarily composed of Plan Physicians, selects drugs for the drug formulary based on a number of factors, including safety and effectiveness as determined from a review of medical literature. The Pharmacy and Therapeutics Committee meets at least quarterly to consider additions and deletions based on new information or drugs that become available. If you would like to request a copy of our drug formulary, please call our Member Service Contact Center. Note: The presence of a drug on our drug formulary does not necessarily mean that your Plan Physician will prescribe it for a particular medical condition.

Our drug formulary guidelines allow you to obtain nonformulary prescription drugs (those not listed on our drug formulary for your condition) if they would otherwise be covered and a Plan Physician determines that they are Medically Necessary. If you disagree with your Plan Physician's determination that a nonformulary prescription drug is not Medically Necessary, you may file a grievance as described in the "Dispute Resolution" section. Also, our formulary guidelines may require you to participate in a behavioral intervention program approved by the Medical Group for specific conditions and you may be required to pay for the program.

About specialty drugs Specialty drugs are high-cost drugs that are on our specialty drug list. To obtain a list of specialty drugs that are on our formulary, or to find out if a nonformulary drug is on the specialty drug list, please call our Member Service Contact Center.

General rules about coverage and your Cost Share We cover the following outpatient drugs, supplies, and supplements as described in this "Outpatient Prescription Drugs, Supplies, and Supplements" section:

• Drugs for which a prescription is required by law. We also cover certain drugs that do not require a prescription by law if they are listed on our drug formulary

• Disposable needles and syringes needed for injecting covered drugs and supplements

• Inhaler spacers needed to inhale covered drugs


Note: • If Charges for the drug, supply, or supplement are

less than the Copayment, you will pay the lesser amount

• Items can change tier at any time, in accord with formulary guidelines, which may impact your Cost Share (for example, if a brand-name drug is added to the specialty drug list, you will pay the Cost Share that applies to drugs on the specialty drug tier, not the Cost Share for drugs on the brand-name drug tier)

Continuity drugs. If this Membership Agreement and Evidence of Coverage is amended to exclude a drug that we have been covering and providing to you under this Membership Agreement and Evidence of Coverage, we will continue to provide the drug if a prescription is required by law and a Plan Physician continues to prescribe the drug for the same condition and for a use approved by the federal Food and Drug Administration: • Generic continuity drugs: 50% Coinsurance for up

to a 30-day supply in any 30-day period • Brand-name continuity drugs: 50% Coinsurance for

up to a 30-day supply in any 30-day period

Mail order service. Prescription refills can be mailed within 7 to 10 days at no extra cost for standard U.S. postage. The appropriate Cost Share (according to your drug coverage) will apply and must be charged to a valid credit card.

You may request mail order service in the following ways: • To order online, visit kp.org/rxrefill (you can

register for a secure account at kp.org/registernow) or use the kp.org app from your Web-enabled phone or mobile device

• Call the pharmacy phone number highlighted on your prescription label and select the mail delivery option

• On your next visit to a Kaiser Permanente pharmacy, ask our staff how you can have your prescriptions mailed to you

Note: Not all drugs can be mailed; restrictions and limitations apply.

Coverage and your Cost Share for most items Drugs, supplies, and supplements are covered as follows except for items listed under "Other items:"

Item Your Cost Share Plan Pharmacy By Mail

Items on the generic tier

$5 for up to a 30-day supply


Item Your Cost Share

Plan Pharmacy By Mail Items on the brand-name tier



Items on the specialty tier 10% Coinsurance

for up to a 100-day supply

Availability for mail order varies by item. Talk to

your local pharmacy

Other items Coverage and your Cost Share listed above for most items does not apply to the items list under "Other items." Coverage and your Cost Share for these other items is as follows:

Base Drugs, Supplies, and Supplements


Plan Pharmacy By Mail Hematopoietic agents for dialysis

No charge for up to a 30-day supply Not available

Elemental dietary enteral formula when used as a primary therapy for regional enteritis


Items listed below on the generic tier



your local pharmacy

Items listed below on the brand-name tier



your local pharmacy

Items listed below on the specialty tier

10% Coinsurance for up to a 100-day

supply


your local pharmacy

• Drugs for the treatment of tuberculosis

• Certain drugs for the treatment of life-threatening ventricular arrhythmia

• Human growth hormone for long-term treatment of pediatric patients with growth failure from lack of adequate endogenous growth hormone secretion

• Hematopoietic agents for the treatment of anemia in chronic renal insufficiency


Base Drugs, Supplies, and Supplements

• Immunosuppressants and ganciclovir and ganciclovir prodrugs for the treatment of cytomegalovirus when prescribed in connection with a transplant

• Phosphate binders for dialysis patients for the treatment of hyperphosphatemia in end stage renal disease

Anticancer Drugs and Certain Critical Adjuncts

Following a Diagnosis of Cancer


Plan Pharmacy By Mail

Oral anticancer drugs on the generic tier



your local pharmacy

Oral anticancer drugs on the brand-name tier $15 for up to a 30-

day supply


your local pharmacy

Oral anticancer drugs on the specialty tier

10% Coinsurance (not to exceed

$200) for up to a 100-day supply


your local pharmacy

Non-oral anticancer drugs on the generic tier $5 for up to a 30-

day supply


your local pharmacy

Non-oral anticancer drugs on the brand-name tier $15 for up to a 30-

day supply


your local pharmacy

Non-oral anticancer drugs on the specialty tier


supply


your local pharmacy

Home Infusion Drugs


Home infusion drugs


Home Infusion Drugs Supplies necessary for administration of home infusion drugs

No charge No charge

Home infusion drugs are self-administered intravenous drugs, fluids, additives, and nutrients that require specific types of parenteral-infusion, such as an intravenous or intraspinal-infusion. Diabetes Supplies and Amino Acid–Modified Products


Plan Pharmacy By Mail Amino acid–modified products used to treat congenital errors of amino acid metabolism (such as phenylketonuria)


Ketone test strips and sugar or acetone test tablets or tapes for diabetes urine testing

No charge for up to a 100-day

supply Not available

Insulin-administration devices: pen delivery devices, disposable needles and syringes, and visual aids required to ensure proper dosage (except eyewear)



your local pharmacy

Note: Drugs related to the treatment of diabetes (for example, insulin) are not covered under this "Diabetes supplies and amino-acid modified products" section

Contraceptive Drugs and Devices


Plan Pharmacy By Mail Oral contraceptives, contraceptive rings, and contraceptive patches on the generic tier that require a prescription by law


supply


supply Contraceptive rings are not available for mail order


Contraceptive Drugs and Devices Oral contraceptives, contraceptive rings, and contraceptive patches on the brand-name tier that require a prescription by law


supply


supply Contraceptive rings are not available for mail order

Contraceptive items for women that do not require a prescription by law when prescribed by a Plan Provider

No charge Not available

Emergency contraception that requires a prescription by law

No charge Not available

Diaphragms and cervical caps No charge Not available

Certain Preventive Items


Plan Pharmacy By Mail The Preventive Care Services items listed below when prescribed by a Plan Provider


supply Not available

• Aspirin to reduce the risk of heart attack

• Folic acid supplements for pregnant women to reduce the risk of birth defects

• Fluoride supplements for children to reduce the risk of tooth decay

• Iron supplements for children

• Vitamin D supplements for adults to prevent falls

• Medications for the prevention of breast cancer

Infertility and Sexual Dysfunction Drugs


Infertility drugs Not covered Not covered GIFT, ZIFT, and IVF drugs Not covered Not covered

Sexual dysfunction drugs on the generic tier



Sexual dysfunction drugs on the brand-name tier



Infertility and Sexual Dysfunction Drugs Sexual dysfunction drugs on the specialty tier


supply


your local pharmacy

Coverage for Services related to "Outpatient Prescription Drugs, Supplies, and Supplements" described in other sections Coverage for the following Services is described under these headings in this "Benefits and Your Cost Share" section: • Diabetes blood-testing equipment and their supplies,

and insulin pumps and their supplies (refer to "Durable Medical Equipment for Home Use")

• Drugs covered during a covered stay in a Plan Hospital or Skilled Nursing Facility (refer to "Hospital Inpatient Care" and "Skilled Nursing Facility Care")

• Drugs prescribed for pain control and symptom management of the terminal illness for Members who are receiving covered hospice care (refer to "Hospice Care")

• Durable medical equipment used to administer drugs (refer to "Durable Medical Equipment for Home Use")


Outpatient prescription drugs, supplies, and supplements exclusions • Any requested packaging (such as dose packaging)

other than the dispensing pharmacy's standard packaging

• Compounded products unless the drug is listed on our drug formulary or one of the ingredients requires a prescription by law

• Drugs prescribed to shorten the duration of the common cold

Prosthetic and Orthotic Devices We cover the prosthetic and orthotic devices specified in this "Prosthetic and Orthotic Devices" section if all of the following requirements are met:

• The device is in general use, intended for repeated use, and primarily and customarily used for medical purposes

• The device is the standard device that adequately meets your medical needs


• You receive the device from the provider or vendor that we select

Coverage includes fitting and adjustment of these devices, their repair or replacement, and Services to determine whether you need a prosthetic or orthotic device. If we cover a replacement device, then you pay the Cost Share that you would pay for obtaining that device.

Prosthetic and orthotic devices that are essential health benefits Internally implanted devices. We cover prosthetic and orthotic devices such as pacemakers, intraocular lenses, cochlear implants, osseointegrated hearing devices, and hip joints, if they are implanted during a surgery that we are covering under another section of this "Benefits and Your Cost Share" section. We cover these devices at no charge.

External devices. We cover the following external prosthetic and orthotic devices at no charge: • Prosthetic devices and installation accessories to

restore a method of speaking following the removal of all or part of the larynx (this coverage does not include electronic voice-producing machines, which are not prosthetic devices)

• Prostheses needed after a Medically Necessary mastectomy, including custom-made prostheses when Medically Necessary and up to three brassieres required to hold a prosthesis every 12 months

• Podiatric devices (including footwear) to prevent or treat diabetes-related complications when prescribed by a Plan Physician or by a Plan Provider who is a podiatrist

• Compression burn garments and lymphedema wraps and garments

• Enteral formula for Members who require tube feeding in accord with Medicare guidelines

• Prostheses to replace all or part of an external facial body part that has been removed or impaired as a result of disease, injury, or congenital defect

Prosthetic and orthotic devices that are not essential health benefits Prosthetic and orthotic devices that are not essential health benefits are not covered.

Coverage for Services related to "Prosthetic and Orthotic Devices" described in other sections Coverage for the following Services is described under these headings in this "Benefits and Your Cost Share" section:

• Eyeglasses and contact lenses (refer to "Vision Services")

Prosthetic and orthotic devices exclusions • Multifocal intraocular lenses and intraocular lenses to

correct astigmatism

• Nonrigid supplies, such as elastic stockings and wigs, except as otherwise described above in this "Prosthetic and Orthotic Devices" section

• Comfort, convenience, or luxury equipment or features

• Repair or replacement of device due to loss or misuse

• Shoes, shoe inserts, arch supports, or any other footwear, even if custom-made, except footwear described above in this "Prosthetic and Orthotic Devices" section for diabetes-related complications

• Orthotic devices not intended for maintaining normal activities of daily living (including devices intended to provide additional support for recreational or sports activities)

Reconstructive Surgery We cover the following reconstructive surgery Services:

• Reconstructive surgery to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease, if a Plan Physician determines that it is necessary to improve function, or create a normal appearance, to the extent possible

• Following Medically Necessary removal of all or part of a breast, we cover reconstruction of the breast, surgery and reconstruction of the other breast to produce a symmetrical appearance, and treatment of physical complications, including lymphedemas

You pay the following for covered reconstructive surgery Services: • Hospital inpatient care (including room and board,

drugs, imaging, laboratory, special procedures, and Plan Physician Services): a $250 Copayment per day up to a maximum of $1,250 per admission

• Primary Care Visits for evaluations and treatment: a $20 Copayment per visit

• Specialty Care Visits for consultations, evaluations, and treatment: a $40 Copayment per visit





Coverage for Services related to "Reconstructive Surgery" described in other sections Coverage for the following Services is described under these headings in this "Benefits and Your Cost Share" section: • Dental and orthodontic Services that are an integral

part of reconstructive surgery for cleft palate (refer to "Dental and Orthodontic Services")

• Outpatient imaging and laboratory (refer to "Outpatient Imaging, Laboratory, and Special Procedures")



• Prosthetics and orthotics (refer to "Prosthetic and Orthotic Devices")

Reconstructive surgery exclusions • Surgery that, in the judgment of a Plan Physician

specializing in reconstructive surgery, offers only a minimal improvement in appearance

• Surgery that is performed to alter or reshape normal structures of the body in order to improve appearance

Rehabilitative and Habilitative Services We cover the Services described in this "Rehabilitative and Habilitative Services" section if all of the following requirements are met:

• The Services are to address a health condition

• The Services are to help you partially or fully acquire or improve skills and functioning needed to perform activities of daily living, to the maximum extent practical

We cover the following Services at the Cost Share indicated: • Individual outpatient physical, occupational, and

speech therapy related to pervasive developmental disorder or autism: a $20 Copayment per visit

• Group outpatient physical, occupational, and speech therapy related to pervasive developmental disorder or autism: a $10 Copayment per visit

• Group and individual physical therapy prescribed by a Plan Provider to prevent falls: no charge

• All other individual outpatient physical, occupational, and speech therapy: a $20 Copayment per visit

• All other group outpatient physical, occupational, and speech therapy: a $10 Copayment per visit

• Physical, occupational, and speech therapy provided in an organized, multidisciplinary rehabilitation day-treatment program: a $20 Copayment per day

• Physical, occupational, and speech therapy provided in a Skilled Nursing Facility (subject to the day limits described in the "Skilled Nursing Facility Care" section): You pay the Cost Share for Skilled Nursing Facility care as described under "Skilled Nursing Facility Care" in this "Benefits and Your Cost Share" section

• Physical, occupational, and speech therapy provided in an inpatient hospital (including treatment in an organized multidisciplinary rehabilitation program): You pay the Cost Share for inpatient care as described under "Hospital Inpatient Care" in this "Benefits and Your Cost Share" section

Coverage for Services related to "Rehabilitative and Habilitative Services" described in other sections • Behavioral health treatment for pervasive

developmental disorder or autism (refer to "Behavioral Health Treatment for Pervasive Developmental Disorder or Autism")

• Home health care (refer to "Home Health Care")


• Durable medical equipment (refer to "Durable Medical Equipment for Home Use")

• Ostomy and urological supplies (refer to "Ostomy and Urological Supplies")

• Prosthetic and orthotic devices (refer to "Prosthetic and Orthotic Devices")

Rehabilitative and Habilitative Services exclusions • Items and services that are not health care items and

services (for example, respite care, day care, recreational care, residential treatment, social services, custodial care, or education services of any kind, including vocational training)

Services in Connection with a Clinical Trial We cover Services you receive in connection with a clinical trial if all of the following requirements are met: • We would have covered the Services if they were not

related to a clinical trial • You are eligible to participate in the clinical trial

according to the trial protocol with respect to treatment of cancer or other life-threatening condition (a condition from which the likelihood of death is probable unless the course of the condition is interrupted), as determined in one of the following ways: ♦ A Plan Provider makes this determination ♦ You provide us with medical and scientific

information establishing this determination • If any Plan Providers participate in the clinical trial

and will accept you as a participant in the clinical trial, you must participate in the clinical trial through a Plan Provider unless the clinical trial is outside the state where you live

• The clinical trial is an Approved Clinical Trial

"Approved Clinical Trial" means a phase I, phase II, phase III, or phase IV clinical trial related to the prevention, detection, or treatment of cancer or other life-threatening condition and it meets one of the following requirements: • The study or investigation is conducted under an

investigational new drug application reviewed by the U.S. Food and Drug Administration

• The study or investigation is a drug trial that is exempt from having an investigational new drug application

• The study or investigation is approved or funded by at least one of the following: ♦ the National Institutes of Health ♦ the Centers for Disease Control and Prevention ♦ the Agency for Health Care Research and Quality ♦ the Centers for Medicare & Medicaid Services ♦ a cooperative group or center of any of the above

entities or of the Department of Defense or the Department of Veterans Affairs

♦ a qualified non-governmental research entity identified in the guidelines issued by the National Institutes of Health for center support grants

♦ the Department of Veterans Affairs or the Department of Defense or the Department of Energy, but only if the study or investigation has been reviewed and approved though a system of peer review that the U.S. Secretary of Health and Human Services determines meets all of the following requirements: (1) It is comparable to the National Institutes of Health system of peer review of studies and investigations and (2) it assures unbiased review of the highest scientific standards by qualified people who have no interest in the outcome of the review

For covered Services related to a clinical trial, you will pay the Cost Share you would pay if the Services were not related to a clinical trial. For example, see "Hospital Inpatient Care" in this "Benefits and Your Cost Share" section for the Cost Share that applies for hospital inpatient care.

Services in connection with a clinical trial exclusions • The investigational Service • Services that are provided solely to satisfy data

collection and analysis needs and are not used in your clinical management

Skilled Nursing Facility Care Inside your Home Region Service Area, we cover at a $150 Copayment per day up to a maximum of $750 per admission up to 100 days per benefit period (including any days we covered under any other evidence of coverage) of skilled inpatient Services in a Plan Skilled Nursing Facility. The skilled inpatient Services must be customarily provided by a Skilled Nursing Facility, and above the level of custodial or intermediate care.

A benefit period begins on the date you are admitted to a hospital or Skilled Nursing Facility at a skilled level of


care. A benefit period ends on the date you have not been an inpatient in a hospital or Skilled Nursing Facility, receiving a skilled level of care, for 60 consecutive days. A new benefit period can begin only after any existing benefit period ends. A prior three-day stay in an acute care hospital is not required.

We cover the following Services: • Physician and nursing Services

• Room and board

• Drugs prescribed by a Plan Physician as part of your plan of care in the Plan Skilled Nursing Facility in accord with our drug formulary guidelines if they are administered to you in the Plan Skilled Nursing Facility by medical personnel

• Durable medical equipment in accord with our durable medical equipment formulary if Skilled Nursing Facilities ordinarily furnish the equipment

• Imaging and laboratory Services that Skilled Nursing Facilities ordinarily provide

• Medical social services

• Blood, blood products, and their administration

• Medical supplies

• Behavioral health treatment for pervasive developmental disorder or autism


Coverage for Services related to "Skilled Nursing Facility Care" described in other sections Coverage for the following Services is described under these headings in this "Benefits and Your Cost Share" section: • Outpatient imaging, laboratory, and special

procedures (refer to "Outpatient Imaging, Laboratory, and Special Procedures")

• Physical, occupational, and speech therapy (refer to "Rehabilitative and Habilitative Services")

Transplant Services We cover transplants of organs, tissue, or bone marrow if the Medical Group provides a written referral for care to a transplant facility as described in "Medical Group authorization procedure for certain referrals" under "Getting a Referral" in the "How to Obtain Services" section.

After the referral to a transplant facility, the following applies:

• If either the Medical Group or the referral facility determines that you do not satisfy its respective criteria for a transplant, we will only cover Services you receive before that determination is made

• Health Plan, Plan Hospitals, the Medical Group, and Plan Physicians are not responsible for finding, furnishing, or ensuring the availability of an organ, tissue, or bone marrow donor

• In accord with our guidelines for Services for living transplant donors, we provide certain donation-related Services for a donor, or an individual identified by the Medical Group as a potential donor, whether or not the donor is a Member. These Services must be directly related to a covered transplant for you, which may include certain Services for harvesting the organ, tissue, or bone marrow and for treatment of complications. Please call our Member Service Contact Center for questions about donor Services

For covered transplant Services that you receive, you will pay the Cost Share you would pay if the Services were not related to a transplant. For example, see "Hospital Inpatient Care" in this "Benefits and Your Cost Share" section for the Cost Share that applies for hospital inpatient care.

We provide or pay for donation-related Services for actual or potential donors (whether or not they are Members) in accord with our guidelines for donor Services at no charge.

Coverage for Services related to "Transplant Services" described in other sections Coverage for the following Services is described under these headings in this "Benefits and Your Cost Share" section: • Outpatient imaging and laboratory (refer to

"Outpatient Imaging, Laboratory, and Special Procedures")



Vision Services We cover the following:

• Routine eye exams with a Plan Optometrist for Members under age 19 to determine the need for


vision correction and to provide a prescription for eyeglass lenses: no charge

• Routine eye exams with a Plan Optometrist for Members age 19 or older to determine the need for vision correction and to provide a prescription for eyeglass lenses: Not covered

• Specialty Care Visits to diagnose and treat injuries or diseases of the eye: a $40 Copayment per visit

• Up to two Medically Necessary contact lenses per eye (including fitting and dispensing) in any 12-month period for aniridia (missing iris) at Plan Medical Offices or Plan Optical Sales Offices when prescribed by a Plan Physician or Plan Optometrist: no charge. We will not cover an aniridia contact lens if we covered more than one aniridia contact lens for that eye within the previous 12 months (including when we provided an Allowance toward, or otherwise covered, one or more aniridia contact lenses under any other evidence of coverage)

Eyeglasses and contact lenses for Members under age 19 We cover the Services described in this "Eyeglasses and contact lenses for Members under age 19" section at Plan Medical Offices or Plan Optical Sales Offices.

Eyeglasses. If you prefer to wear eyeglasses rather than contact lenses, we cover one complete pair of eyeglasses (frame and Regular Eyeglass Lenses) from our designated value frame collection at no charge per calendar year when prescribed by a physician or optometrist and a Plan Provider puts the lenses into an eyeglass frame.

"Regular Eyeglass Lenses" for Members under age 19 are lenses that meet all of the following requirements:

• They are clear glass, plastic, or polycarbonate lenses

• At least one of the two lenses has refractive value

• They are single vision, flat top multifocal, or lenticular

Eyeglass warranty: Eyeglasses purchased at a Plan Optical Sales Office may include a replacement warranty for up to one year from the original date of dispensing. Please ask your Plan Optical Sales Office for warranty information.

Special contact lenses. We cover the following at the Cost Share indicated: • For aphakia (absence of the crystalline lens of the

eye), we cover up to six Medically Necessary aphakic contact lenses per eye (including fitting and dispensing) per calendar year for Members through

age 9 at no charge when prescribed by a Plan Physician or Plan Optometrist

• If a Plan Physician or Plan Optometrist prescribes contact lenses that will provide a significant improvement in your vision that eyeglass lenses cannot provide, we cover either one pair of contact lenses (including fitting and dispensing) or an initial supply of disposable contact lenses (including fitting and dispensing) in a 12-month period at no charge

Other contact lenses. If you prefer to wear contact lenses rather than eyeglasses, we cover the following (including fitting and dispensing) at no charge when prescribed by a physician or optometrist and obtained at a Plan Medical Office or Plan Optical Sales Office: • Standard contact lenses: one pair of lenses per

calendar year; or • Disposable contact lenses: one 6 month supply for

each eye per calendar year

Low vision devices for Members under age 19 If a low vision device will provide a significant improvement in your vision not obtainable with eyeglasses or contact lenses (or with a combination of eyeglasses and contact lenses), we cover one device (including fitting and dispensing) at no charge per calendar year.

Low vision devices for Members age 19 and older

Low vision devices for Members age 19 and older (including fitting and dispensing) are not covered.

Coverage for Services related to "Vision Services" described in other sections Coverage for the following Services is described under other headings in this "Benefits and Your Cost Share" section: • Routine vision screenings when performed as part of

a routine physical maintenance exam (refer to "Outpatient Care")

• Services related to the eye or vision other than Services covered under this "Vision Services" section, such as outpatient surgery and outpatient prescription drugs, supplies, and supplements (refer to the applicable heading in this "Benefits and Your Cost Share" section)

Vision Services exclusions • Eye exams for refraction for Members age 19 and

older

• Industrial frames


• Contact lenses, including fitting and dispensing, for Members age 19 and older (except for special contact lenses to treat aniridia as described under this "Vision Services" section)

• Eyeglass lenses and frames for Members age 19 and older

• Eye exams for the purpose of obtaining or maintaining contact lenses for Members age 19 and older (except for contact lenses for aniridia as described in this "Vision Services" section)

• Low vision devices for Members age 19 and older

• Except for Regular Eyeglass Lenses described in this "Vision Services" section all other lenses such as progressive and High-Index lenses

• Lenses and sunglasses without refractive value except for a clear balance lens if only one eye needs correction

• Tinted lenses except when Medically Necessary to treat macular degeneration or retinitis pigmentosa

• Photochromatic or polarized lenses

• Antireflective coating

• Replacement of lost or stolen eyewear

• Replacement of broken or damaged contact lenses, eyeglass lenses, and frames, except as described in warranty information provided to you at the time of purchase

• Replacement of broken or damaged low vision devices

• Eyeglass or contact lens adornment, such as engraving, faceting, or jeweling

• Items that do not require a prescription by law (other than eyeglass frames), such as eyeglass holders, eyeglass cases, and repair kits

Exclusions, Limitations, Coordination of Benefits, and Reductions

Exclusions The items and services listed in this "Exclusions" section are excluded from coverage. These exclusions apply to all Services that would otherwise be covered under this Membership Agreement and Evidence of Coverage regardless of whether the services are within the scope of a provider's license or certificate. Additional exclusions that apply only to a particular benefit are listed in the

description of that benefit in the "Benefits and Your Cost Share" section.

Certain exams and Services Physical exams and other Services (1) required for obtaining or maintaining employment or participation in employee programs, (2) required for insurance or licensing, or (3) on court order or required for parole or probation. This exclusion does not apply if a Plan Physician determines that the Services are Medically Necessary.

Chiropractic Services Chiropractic Services and the Services of a chiropractor, unless you have coverage for supplemental chiropractic Services as described in an amendment to this Membership Agreement and Evidence of Coverage.

Cosmetic Services Services that are intended primarily to change or maintain your appearance, except that this exclusion does not apply to any of the following: • Services covered under "Reconstructive Surgery" in

the "Benefits and Your Cost Share" section

• The following devices covered under "Prosthetic and Orthotic Devices" in the "Benefits and Your Cost Share" section: testicular implants implanted as part of a covered reconstructive surgery, breast prostheses needed after a mastectomy, and prostheses to replace all or part of an external facial body part

Custodial care Assistance with activities of daily living (for example: walking, getting in and out of bed, bathing, dressing, feeding, toileting, and taking medicine).

This exclusion does not apply to assistance with activities of daily living that is provided as part of covered hospice, Skilled Nursing Facility, or inpatient hospital care.

Dental and orthodontic Services Dental and orthodontic Services such as X-rays, appliances, implants, Services provided by dentists or orthodontists, dental Services following accidental injury to teeth, and dental Services resulting from medical treatment such as surgery on the jawbone and radiation treatment.

This exclusion does not apply to Services covered under "Dental and Orthodontic Services" in the "Benefits and Your Cost Share" section or to pediatric dental Services described in a Pediatric Dental Services Amendment to this Membership Agreement and Evidence of Coverage.


Disposable supplies Disposable supplies for home use, such as bandages, gauze, tape, antiseptics, dressings, Ace-type bandages, and diapers, underpads, and other incontinence supplies.

This exclusion does not apply to disposable supplies covered under "Durable Medical Equipment for Home Use," "Home Health Care," "Hospice Care," "Ostomy and Urological Supplies," and "Outpatient Prescription Drugs, Supplies, and Supplements" in the "Benefits and Your Cost Share" section.

Experimental or investigational Services A Service is experimental or investigational if we, in consultation with the Medical Group, determine that one of the following is true: • Generally accepted medical standards do not

recognize it as safe and effective for treating the condition in question (even if it has been authorized by law for use in testing or other studies on human patients)

• It requires government approval that has not been obtained when the Service is to be provided

This exclusion does not apply to any of the following:

• Experimental or investigational Services when an investigational application has been filed with the federal Food and Drug Administration (FDA) and the manufacturer or other source makes the Services available to you or Kaiser Permanente through an FDA-authorized procedure, except that we do not cover Services that are customarily provided by research sponsors free of charge to enrollees in a clinical trial or other investigational treatment protocol

• Services covered under "Services in Connection with a Clinical Trial" in the "Benefits and Your Cost Share" section

Please refer to the "Dispute Resolution" section for information about Independent Medical Review related to denied requests for experimental or investigational Services.

Hair loss or growth treatment Items and services for the promotion, prevention, or other treatment of hair loss or hair growth.

Intermediate care Care in a licensed intermediate care facility. This exclusion does not apply to Services covered under "Durable Medical Equipment," "Home Health Care," and "Hospice Care" in the "Benefits and Your Cost Share" section.

Items and services that are not health care items and services For example, we do not cover: • Teaching manners and etiquette

• Teaching and support services to develop planning skills such as daily activity planning and project or task planning

• Items and services for the purpose of increasing academic knowledge or skills

• Teaching and support services to increase intelligence

• Academic coaching or tutoring for skills such as grammar, math, and time management

• Teaching you how to read, whether or not you have dyslexia

• Educational testing

• Teaching art, dance, horse riding, music, play or swimming, except that this exclusion for "teaching play" does not apply to Services that are part of a behavioral health therapy treatment plan and covered under "Behavioral Health Treatment for Pervasive Developmental Disorder or Autism" in the "Benefits and Your Cost Share" section

• Teaching skills for employment or vocational purposes

• Vocational training or teaching vocational skills

• Professional growth courses

• Training for a specific job or employment counseling

• Aquatic therapy and other water therapy, except that this exclusion for aquatic therapy and other water therapy does not apply to therapy Services that are part of a physical therapy treatment plan and covered under "Home Health Care," "Hospice Services," or "Rehabilitative and Habilitative Services" in the "Benefits and Your Cost Share" section

Items and services to correct refractive defects of the eye Items and services (such as eye surgery or contact lenses to reshape the eye) for the purpose of correcting refractive defects of the eye such as myopia, hyperopia, or astigmatism.

Massage therapy Massage therapy, except that this exclusion does not apply to therapy Services that are part of a physical therapy treatment plan and covered under "Home Health Care," "Hospice Services," or "Rehabilitative and Habilitative Services" in the "Benefits and Your Cost Share" section.


Oral nutrition Outpatient oral nutrition, such as dietary supplements, herbal supplements, weight loss aids, formulas, and food.

This exclusion does not apply to any of the following:

• Amino acid–modified products and elemental dietary enteral formula covered under "Outpatient Prescription Drugs, Supplies, and Supplements" in the "Benefits and Your Cost Share" section

• Enteral formula covered under "Prosthetic and Orthotic Devices" in the "Benefits and Your Cost Share" section

Residential care Care in a facility where you stay overnight, except that this exclusion does not apply when the overnight stay is part of covered care in a hospital, a Skilled Nursing Facility, inpatient respite care covered in the "Hospice Care" section, a licensed facility providing crisis residential Services covered under "Inpatient psychiatric hospitalization and intensive psychiatric treatment programs" in the "Mental Health Services" section, or a licensed facility providing transitional residential recovery Services covered under the "Chemical Dependency Services" section.

Routine foot care items and services Routine foot care items and services that are not Medically Necessary.

Services not approved by the federal Food and Drug Administration Drugs, supplements, tests, vaccines, devices, radioactive materials, and any other Services that by law require federal Food and Drug Administration (FDA) approval in order to be sold in the U.S. but are not approved by the FDA. This exclusion applies to Services provided anywhere, even outside the U.S.

This exclusion does not apply to any of the following: • Services covered under the "Emergency Services and

Urgent Care" section that you receive outside the U.S. • Experimental or investigational Services when an

investigational application has been filed with the FDA and the manufacturer or other source makes the Services available to you or Kaiser Permanente through an FDA-authorized procedure, except that we do not cover Services that are customarily provided by research sponsors free of charge to enrollees in a clinical trial or other investigational treatment protocol

• Services covered under "Services in Connection with a Clinical Trial" in the "Benefits and Your Cost Share" section

Please refer to the "Dispute Resolution" section for information about Independent Medical Review related to denied requests for experimental or investigational Services.

Services performed by unlicensed people Services that are performed safely and effectively by people who do not require licenses or certificates by the state to provide health care services and where the Member's condition does not require that the services be provided by a licensed health care provider.

This exclusion does not apply to Services covered under "Behavioral Health Treatment for Pervasive Developmental Disorder or Autism" in the "Benefits and Your Cost Share" section.

Services related to a noncovered Service When a Service is not covered, all Services related to the noncovered Service are excluded, except for Services we would otherwise cover to treat complications of the noncovered Service. For example, if you have a noncovered cosmetic surgery, we would not cover Services you receive in preparation for the surgery or for follow-up care. If you later suffer a life-threatening complication such as a serious infection, this exclusion would not apply and we would cover any Services that we would otherwise cover to treat that complication.

Surrogacy Services for anyone in connection with a Surrogacy Arrangement, except for otherwise-covered Services provided to a Member who is a surrogate. A "Surrogacy Arrangement" is one in which a woman (the surrogate) agrees to become pregnant and to surrender the baby (or babies) to another person or persons who intend to raise the child (or children), whether or not the woman receives payment for being a surrogate. Please refer to "Surrogacy arrangements" under "Reductions" in this "Exclusions, Limitations, Coordination of Benefits, and Reductions" section for information about your obligations to us in connection with a Surrogacy Arrangement, including your obligations to reimburse us for any Services we cover and to provide information about anyone who may be financially responsible for Services the baby (or babies) receive.

Travel and lodging expenses Travel and lodging expenses, except for the following: • In some situations if the Medical Group refers you to

a Non–Plan Provider as described in "Medical Group


authorization procedure for certain referrals" under "Getting a Referral" in the "How to Obtain Services" section, we may pay certain expenses that we preauthorize in accord with our travel and lodging guidelines. Please call our Member Service Contact Center for questions about travel and lodging

• Reimbursement for travel and lodging expenses provided under "Bariatric Surgery" in the "Benefits and Your Cost Share" section

Limitations We will make a good faith effort to provide or arrange for covered Services within the remaining availability of facilities or personnel in the event of unusual circumstances that delay or render impractical the provision of Services under this Membership Agreement and Evidence of Coverage, such as a major disaster, epidemic, war, riot, civil insurrection, disability of a large share of personnel at a Plan Facility, complete or partial destruction of facilities, and labor dispute. Under these circumstances, if you have an Emergency Medical Condition, call 911 or go to the nearest hospital as described under "Emergency Services" in the "Emergency Services and Urgent Care" section, and we will provide coverage and reimbursement as described in that section.

Additional limitations that apply only to a particular benefit are listed in the description of that benefit in the "Benefits and Your Cost Share" section.

Coordination of Benefits If you have Medicare coverage, we will coordinate benefits with your Medicare coverage under Medicare rules. Medicare rules determine which coverage pays first, or is "primary," and which coverage pays second, or is "secondary." You must give us any information we request to help us coordinate benefits. Please call our Member Service Contact Center to find out which Medicare rules apply to your situation, and how payment will be handled.

Reductions

Employer responsibility For any Services that the law requires an employer to provide, we will not pay the employer, and when we cover any such Services we may recover the value of the Services from the employer.

Government agency responsibility For any Services that the law requires be provided only by or received only from a government agency, we will not pay the government agency, and when we cover any such Services we may recover the value of the Services from the government agency.

Injuries or illnesses alleged to be caused by third parties If you obtain a judgment or settlement from or on behalf of a third party who allegedly caused an injury or illness for which you received covered Services, you must pay us Charges for those Services, except that the amount you must pay will not exceed the maximum amount allowed under California Civil Code Section 3040. Note: This "Injuries or illnesses alleged to be caused by third parties" section does not affect your obligation to pay your Cost Share for these Services, but we will credit any such payments toward the amount you must pay us under this paragraph.

To the extent permitted or required by law, we have the option of becoming subrogated to all claims, causes of action, and other rights you may have against a third party or an insurer, government program, or other source of coverage for monetary damages, compensation, or indemnification on account of the injury or illness allegedly caused by the third party. We will be so subrogated as of the time we mail or deliver a written notice of our exercise of this option to you or your attorney, but we will be subrogated only to the extent of the total of Charges for the relevant Services.

To secure our rights, we will have a lien on the proceeds of any judgment or settlement you or we obtain against a third party. The proceeds of any judgment or settlement that you or we obtain shall first be applied to satisfy our lien, regardless of whether the total amount of the proceeds is less than the actual losses and damages you incurred.

Within 30 days after submitting or filing a claim or legal action against a third party, you must send written notice of the claim or legal action to:

For Northern California Members: Trover Solutions, Inc. Kaiser Permanente – Northern California Region Subrogation Mailbox 9390 Bunsen Parkway Louisville, KY 40220


For Southern California Members: The Rawlings Group Subrogation Mailbox P.O. Box 2000 LaGrange, KY 40031

In order for us to determine the existence of any rights we may have and to satisfy those rights, you must complete and send us all consents, releases, authorizations, assignments, and other documents, including lien forms directing your attorney, the third party, and the third party's liability insurer to pay us directly. You may not agree to waive, release, or reduce our rights under this provision without our prior, written consent.

If your estate, parent, guardian, or conservator asserts a claim against a third party based on your injury or illness, your estate, parent, guardian, or conservator and any settlement or judgment recovered by the estate, parent, guardian, or conservator shall be subject to our liens and other rights to the same extent as if you had asserted the claim against the third party. We may assign our rights to enforce our liens and other rights.

If you have Medicare, Medicare law may apply with respect to Services covered by Medicare.

Some providers have contracted with Kaiser Permanente to provide certain Services to Members at rates that are typically less than the fees that the providers ordinarily charge to the general public ("General Fees"). However, these contracts may allow the providers to recover all or a portion of the difference between the fees paid by Kaiser Permanente and their General Fees by means of a lien claim under California Civil Code Sections 3045.1–3045.6 against a judgment or settlement that you receive from or on behalf of a third party. For Services the provider furnished, our recovery and the provider's recovery together will not exceed the provider's General Fees.

Medicare benefits Your benefits are reduced by any benefits you have under Medicare except for Members whose Medicare benefits are secondary by law.

Surrogacy arrangements If you enter into a Surrogacy Arrangement, you must pay us Charges for covered Services you receive related to conception, pregnancy, delivery, or postpartum care in connection with that arrangement ("Surrogacy Health Services"), except that the amount you must pay will not exceed the payments or other compensation you and any other payee are entitled to receive under the Surrogacy

Arrangement. A "Surrogacy Arrangement" is one in which a woman agrees to become pregnant and to surrender the baby (or babies) to another person or persons who intend to raise the child (or children), whether or not the woman receives payment for being a surrogate. Note: This "Surrogacy arrangements" section does not affect your obligation to pay your Cost Share for these Services, but we will credit any such payments toward the amount you must pay us under this paragraph. After you surrender a baby to the legal parents, you are not obligated to pay Charges for any Services that the baby receives (the legal parents are financially responsible for any Services that the baby receives).

By accepting Surrogacy Health Services, you automatically assign to us your right to receive payments that are payable to you or any other payee under the Surrogacy Arrangement, regardless of whether those payments are characterized as being for medical expenses. To secure our rights, we will also have a lien on those payments and on any escrow account, trust, or any other account that holds those payments. Those payments (and amounts in any escrow account, trust, or other account that holds those payments) shall first be applied to satisfy our lien. The assignment and our lien will not exceed the total amount of your obligation to us under the preceding paragraph.

Within 30 days after entering into a Surrogacy Arrangement, you must send written notice of the arrangement, including all of the following information: • Names, addresses, and telephone numbers of the

other parties to the arrangement

• Names, addresses, and telephone numbers of any escrow agent or trustee

• Names, addresses, and telephone numbers of the intended parents and any other parties who are financially responsible for Services the baby (or babies) receive, including names, addresses, and telephone numbers for any health insurance that will cover Services that the baby (or babies) receive

• A signed copy of any contracts and other documents explaining the arrangement

• Any other information we request in order to satisfy our rights


You must send this information to:

For Northern California Members: Trover Solutions, Inc. Kaiser Permanente – Northern California Region Surrogacy Mailbox 9390 Bunsen Parkway Louisville, KY 40220

For Southern California Members: The Rawlings Group Surrogacy Mailbox P.O. Box 2000 LaGrange, KY 40031

You must complete and send us all consents, releases, authorizations, lien forms, and other documents that are reasonably necessary for us to determine the existence of any rights we may have under this "Surrogacy arrangements" section and to satisfy those rights. You may not agree to waive, release, or reduce our rights under this "Surrogacy arrangements" section without our prior, written consent.

If your estate, parent, guardian, or conservator asserts a claim against a third party based on the surrogacy arrangement, your estate, parent, guardian, or conservator and any settlement or judgment recovered by the estate, parent, guardian, or conservator shall be subject to our liens and other rights to the same extent as if you had asserted the claim against the third party. We may assign our rights to enforce our liens and other rights.

U.S. Department of Veterans Affairs For any Services for conditions arising from military service that the law requires the Department of Veterans Affairs to provide, we will not pay the Department of Veterans Affairs, and when we cover any such Services we may recover the value of the Services from the Department of Veterans Affairs.

Workers' compensation or employer's liability benefits You may be eligible for payments or other benefits, including amounts received as a settlement (collectively referred to as "Financial Benefit"), under workers' compensation or employer's liability law. We will provide covered Services even if it is unclear whether you are entitled to a Financial Benefit, but we may recover the value of any covered Services from the following sources: • From any source providing a Financial Benefit or

from whom a Financial Benefit is due • From you, to the extent that a Financial Benefit is

provided or payable or would have been required to

be provided or payable if you had diligently sought to establish your rights to the Financial Benefit under any workers' compensation or employer's liability law

Post-Service Claims and Appeals

This "Post-Service Claims and Appeals" section explains how to file a claim for payment or reimbursement for Services that you have already received. Please use the procedures in this section in the following situations: • You have received Emergency Services, Post-

Stabilization Care, Out-of-Area Urgent Care, or emergency ambulance Services from a Non–Plan Provider and you want us to pay for the Services

• You have received Services from a Non–Plan Provider that we did not authorize (other than Emergency Services, Out-of-Area Urgent Care, Post-Stabilization Care, or emergency Ambulance Services) and you want us to pay for the Services

• You want to appeal a denial of an initial claim for payment

Please follow the procedures under "Grievances" in the "Dispute Resolution" section in the following situations: • You want us to cover Services that you have not yet

received

• You want us to continue to cover an ongoing course of covered treatment

• You want to appeal a written denial of a request for Services that require prior authorization (as described under "Medical Group authorization procedure for certain referrals")

Who May File The following people may file claims: • You may file for yourself

• You can ask a friend, relative, attorney, or any other individual to file a claim for you by appointing him or her in writing as your authorized representative

• A parent may file for his or her child under age 18, except that the child must appoint the parent as authorized representative if the child has the legal right to control release of information that is relevant to the claim

• A court-appointed guardian may file for his or her ward, except that the ward must appoint the court-appointed guardian as authorized representative if the ward has the legal right to control release of information that is relevant to the claim


• A court-appointed conservator may file for his or her conservatee

• An agent under a currently effective health care proxy, to the extent provided under state law, may file for his or her principal

Authorized representatives must be appointed in writing using either our authorization form or some other form of written notification. The authorization form is available from the Member Services Department at a Plan Facility, on our website at kp.org, or by calling our Member Service Contact Center. Your written authorization must accompany the claim. You must pay the cost of anyone you hire to represent or help you.

Supporting Documents You can request payment or reimbursement orally or in writing. Your request for payment or reimbursement, and any related documents that you give us, constitute your claim.

Claim forms for Emergency Services, Post-Stabilization Care, Out-of-Area Urgent Care, and emergency ambulance Services To file a claim in writing for Emergency Services, Post-Stabilization Care, Out-of-Area Urgent Care, and emergency ambulance Services, please use our claim form. You can obtain a claim form in the following ways:

• By visiting our website at kp.org

• In person from any Member Services office at a Plan Facility and from Plan Providers

• By calling our Member Service Contact Center at 1-800-464-4000 or 1-800-390-3510 (TTY users call 1-800-777-1370 or 711)

Claims forms for all other Services To file a claim in writing for all other Services, you may use our Complaint or Benefit Claim/Request form. You can obtain this form in the following ways: • By visiting our website at kp.org


• By calling our Member Service Contact Center at 1-800-464-4000 (TTY users call 1-800-777-1370 or 711)

Other supporting information When you file a claim, please include any information that clarifies or supports your position. For example, if you have paid for Services, please include any bills

and receipts that support your claim. To request that we pay a Non–Plan Provider for Services, include any bills from the Non–Plan Provider. If the Non–Plan Provider states that they will file the claim, you are still responsible for making sure that we receive everything we need to process the request for payment. When appropriate, we will request medical records from Plan Providers on your behalf. If you tell us that you have consulted with a Non–Plan Provider and are unable to provide copies of relevant medical records, we will contact the provider to request a copy of your relevant medical records. We will ask you to provide us a written authorization so that we can request your records.

If you want to review the information that we have collected regarding your claim, you may request, and we will provide without charge, copies of all relevant documents, records, and other information. You also have the right to request any diagnosis and treatment codes and their meanings that are the subject of your claim. To make a request, you should follow the steps in the written notice sent to you about your claim.

Initial Claims To request that we pay a provider (or reimburse you) for Services that you have already received, you must file a claim. If you have any questions about the claims process, please call our Member Service Contact Center.

Submitting a claim for Emergency Services, Post-Stabilization Care, Out-of-Area Urgent Care, and emergency ambulance Services If you have received Emergency Services, Post-Stabilization Care, Out-of-Area Urgent Care, or emergency ambulance Services from a Non–Plan Provider, then as soon as possible after you received the Services, you must file your claim by mailing a completed claim form and supporting information to the following address:

For Northern California Members: Kaiser Foundation Health Plan, Inc. Claims Department P.O. Box 12923 Oakland, CA 94604-2923

For Southern California Members: Kaiser Foundation Health Plan, Inc. Claims Department P.O. Box 7004 Downey, CA 90242-7004

Please call our Member Service Contact Center if you need help filing your claim.


Submitting a claim for all other Services If you have received Services from a Non–Plan Provider that we did not authorize (other than Emergency Services, Post-Stabilization Care, Out-of-Area Urgent Care, or emergency ambulance Services), then as soon as possible after you receive the Services, you must file your claim in one of the following ways: • By delivering your claim to a Member Services office

at a Plan Facility (please refer to Your Guidebook for addresses)

• By mailing your claim to a Member Services office at a Plan Facility (please refer to Your Guidebook for addresses)



Please call our Member Service Contact Center if you need help filing your claim.

After we receive your claim We will send you an acknowledgement letter within five days after we receive your claim.

After we review your claim, we will respond as follows: • If we have all the information we need we will send

you a written decision within 30 days after we receive your claim. We may extend the time for making a decision for an additional 15 days if circumstances beyond our control delay our decision, if we notify you within 30 days after we receive your claim

• If we need more information, we will ask you for the information before the end of the initial 30-day decision period. We will send our written decision no later than 15 days after the date we receive the additional information. If we do not receive the necessary information within the timeframe specified in our letter, we will make our decision based on the information we have within 15 days after the end of that timeframe

If we pay any part of your claim, we will subtract applicable Cost Share from any payment we make to you or the Non–Plan Provider. You are not responsible for any amounts beyond your Cost Share for covered Emergency Services. If we deny your claim (if we do not agree to pay for all the Services you requested other than the applicable Cost Share), our letter will explain why we denied your claim and how you can appeal.

If you later receive any bills from the Non–Plan Provider for covered Services (other than bills for your Cost

Share), please call our Member Service Contact Center for assistance.

Appeals Claims for Emergency Services, Post-Stabilization Care, Out-of-Area Urgent Care, or emergency ambulance Services from a Non–Plan Provider. If we did not decide fully in your favor and you want to appeal our decision, you may submit your appeal in one of the following ways:

• By mailing your appeal to the Claims Department at the following address:

Kaiser Foundation Health Plan, Inc. Special Services Unit P.O. Box 23280 Oakland, CA 94623



Claims for Services from a Non–Plan Provider that we did not authorize (other than Emergency Services, Post-Stabilization Care, Out-of-Area Urgent Care, or emergency ambulance Services). If we did not decide fully in your favor and you want to appeal our decision, you may submit your appeal in one of the following ways: • By visiting our website at kp.org

• By mailing your appeal to the Member Services Department at a Plan Facility (please refer to Your Guidebook for addresses)



When you file an appeal, please include any information that clarifies or supports your position. If you want to review the information that we have collected regarding your claim, you may request, and we will provide without charge, copies of all relevant documents, records, and other information. To make a request, you should contact or Member Service Contact Center.

Additional information regarding a claim for Services from a Non–Plan Provider that we did not authorize (other than Emergency Services, Post-Stabilization Care, Out-of-Area Urgent Care, or emergency ambulance Services). If we initially denied your


request, you must file your appeal within 180 days after the date you received our denial letter. You may send us information including comments, documents, and medical records that you believe support your claim. If we asked for additional information and you did not provide it before we made our initial decision about your claim, then you may still send us the additional information so that we may include it as part of our review of your appeal. Please send all additional information to the address or fax mentioned in your denial letter.

Also, you may give testimony in writing or by telephone. Please send your written testimony to the address mentioned in our acknowledgement letter, sent to you within five days after we receive your appeal. To arrange to give testimony by telephone, you should call the phone number mentioned in our acknowledgement letter.

We will add the information that you provide through testimony or other means to your appeal file and we will review it without regard to whether this information was filed or considered in our initial decision regarding your request for Services. You have the right to request any diagnosis and treatment codes and their meanings that are the subject of your claim.

We will share any additional information that we collect in the course of our review and we will send it to you. If we believe that your request should not be granted, before we issue our final decision letter, we will also share with you any new or additional reasons for that decision. We will send you a letter explaining the additional information and/or reasons. Our letters about additional information and new or additional rationales will tell you how you can respond to the information provided if you choose to do so. If you do not respond before we must issue our final decision letter, that decision will be based on the information in your appeal file.

We will send you a resolution letter within 30 days after we receive your appeal. If we do not decide in your favor, our letter will explain why and describe your further appeal rights.

External Review You must exhaust our internal claims and appeals procedures before you may request external review unless we have failed to comply with the claims and appeals procedures described in this "Post-Service Claims and Appeals" section. For information about external review process, see "Independent Medical Review (IMR)" in the "Dispute Resolution" section.

Additional Review You may have a right to request review in state court if you remain dissatisfied after you have exhausted our internal claims and appeals procedure, and if applicable, external review.

Dispute Resolution

We are committed to providing you with quality care and with a timely response to your concerns. You can discuss your concerns with our Member Services representatives at most Plan Facilities, or you can call our Member Service Contact Center.

Grievances This "Grievances" section describes our grievance procedure. A grievance is any expression of dissatisfaction expressed by you or your authorized representative through the grievance process. If you want to make a claim for payment or reimbursement for Services that you have already received from a Non–Plan Provider, please follow the procedure in the "Post-Service Claims and Appeals" section.

Here are some examples of reasons you might file a grievance: • You are not satisfied with the quality of care you

received • You received a written denial of Services that require

prior authorization from the Medical Group and you want us to cover the Services

• Your treating physician has said that Services are not Medically Necessary and you want us to cover the Services (including requests for second opinions)

• You were told that Services are not covered and you believe that the Services should be covered

• You want us to continue to cover an ongoing course of covered treatment

• You are dissatisfied with how long it took to get Services, including getting an appointment, in the waiting room, or in the exam room

• You want to report unsatisfactory behavior by providers or staff, or dissatisfaction with the condition of a facility

• We terminated your membership and you disagree with that termination

• We declined your application for coverage and you disagree with our decision


Who may file The following people may file a grievance:

• You may file for yourself

• You can ask a friend, relative, attorney, or any other individual to file a grievance for you by appointing him or her in writing as your authorized representative

• A parent may file for his or her child under age 18, except that the child must appoint the parent as authorized representative if the child has the legal right to control release of information that is relevant to the grievance

• A court-appointed guardian may file for his or her ward, except that the ward must appoint the court-appointed guardian as authorized representative if the ward has the legal right to control release of information that is relevant to the grievance

• A court-appointed conservator may file for his or her conservatee

• An agent under a currently effective health care proxy, to the extent provided under state law, may file for his or her principal

• Your physician may act as your authorized representative with your verbal consent to request an urgent grievance as described under "Urgent procedure" in this "Grievances" section

Authorized representatives must be appointed in writing using either our authorization form or some other form of written notification. The authorization form is available from the Member Services Department at a Plan Facility, on our website at kp.org, or by calling our Member Service Contact Center. Your written authorization must accompany the grievance. You must pay the cost of anyone you hire to represent or help you.

How to file You can file a grievance orally or in writing. Your grievance must explain your issue, such as the reasons why you believe a decision was in error or why you are dissatisfied about Services you received.

To file a grievance in writing, please use our Complaint or Benefit Claim/Request form. You can obtain the form in the following ways: • By visiting our website at kp.org



You must file your grievance within 180 days following the incident or action that is subject to your dissatisfaction. You may send us information including comments, documents, and medical records that you believe support your grievance.

Standard procedure. You must file your grievance in one of the following ways: • By completing a Complaint or Benefit Claim/Request

form at a Member Services office at a Plan Facility (please refer to Your Guidebook for addresses)

• By mailing your grievance to a Member Services office at a Plan Facility (please refer to Your Guidebook for addresses)


• By completing the grievance form on our website at kp.org

Please call our Member Service Contact Center if you need help filing a grievance.

We will send you an acknowledgement letter within five days after we receive your grievance. We will send you a resolution letter within 30 days after we receive your grievance. If you are requesting Services, and we do not decide in your favor, our letter will explain why and describe your further appeal rights.

If you want to review the information that we have collected regarding your grievance, you may request, and we will provide without charge, copies of all relevant documents, records, and other information. To make a request, you should contact our Member Service Contact Center.

Urgent procedure. If you want us to consider your grievance on an urgent basis, please tell us that when you file your grievance.

You must file your urgent grievance in one of the following ways: • By calling our Expedited Review Unit toll free at

1-888-987-7247 (TTY users call 1-800-777-1370 or 711)

• By mailing a written request to: Kaiser Foundation Health Plan, Inc. Expedited Review Unit P.O. Box 23170 Oakland, CA 94623-0170

• By faxing a written request to our Expedited Review Unit toll free at 1-888-987-2252


• By visiting a Member Services office at a Plan Facility (please refer to Your Guidebook for addresses)

• By completing the grievance form on our website at kp.org

We will decide whether your grievance is urgent or non-urgent unless your attending health care provider tells us your grievance is urgent. If we determine that your grievance is not urgent, we will use the procedure described under "Standard procedure" in this "Grievances" section. Generally, a grievance is urgent only if one of the following is true:

• Using the standard procedure could seriously jeopardize your life, health, or ability to regain maximum function

• Using the standard procedure would, in the opinion of a physician with knowledge of your medical condition, subject you to severe pain that cannot be adequately managed without extending your course of covered treatment

• A physician with knowledge of your medical condition determines that your grievance is urgent

If we respond to your grievance on an urgent basis, we will give you oral notice of our decision as soon as your clinical condition requires, but not later than 72 hours after we received your grievance. We will send you a written confirmation of our decision within 3 days after we received your grievance.

If we do not decide in your favor, our letter will explain why and describe your further appeal rights.

Note: If you have an issue that involves an imminent and serious threat to your health (such as severe pain or potential loss of life, limb, or major bodily function), you can contact the California Department of Managed Health Care at any time at 1-888-HMO-2219 (TDD 1-877-688-9891) without first filing a grievance with us.

If you want to review the information that we have collected regarding your grievance, you may request, and we will provide without charge, copies of all relevant documents, records, and other information. To make a request, you should contact our Member Service Contact Center.

Additional information regarding pre-service requests for Medically Necessary Services. You may give testimony in writing or by telephone. Please send your written testimony to the address mentioned in our acknowledgement letter. To arrange to give testimony by

telephone, you should call the phone number mentioned in our acknowledgement letter.

We will add the information that you provide through testimony or other means to your grievance file and we will consider it in our decision regarding your pre-service request for Medically Necessary Services.

We will share any additional information that we collect in the course of our review and we will send it to you. If we believe that your request should not be granted, before we issue our decision letter, we will also share with you any new or additional reasons for that decision. We will send you a letter explaining the additional information and/or reasons. Our letters about additional information and new or additional rationales will tell you how you can respond to the information provided if you choose to do so. If your grievance is urgent, the information will be provided to you orally and followed in writing. If you do not respond before we must issue our final decision letter, that decision will be based on the information in your grievance file.

Additional information regarding appeals of written denials for Services that require prior authorization. You must file your appeal within 180 days after the date you received our denial letter.

You have the right to request any diagnosis and treatment codes and their meanings that are the subject of your appeal.

Also, you may give testimony in writing or by telephone. Please send your written testimony to the address mentioned in our acknowledgement letter. To arrange to give testimony by telephone, you should call the phone number mentioned in our acknowledgement letter.

We will add the information that you provide through testimony or other means to your appeal file and we will consider it in our decision regarding your appeal.

We will share any additional information that we collect in the course of our review and we will send it to you. If we believe that your request should not be granted, before we issue our decision letter, we will also share with you any new or additional reasons for that decision. We will send you a letter explaining the additional information and/or reasons. Our letters about additional information and new or additional rationales will tell you how you can respond to the information provided if you choose to do so. If your appeal is urgent, the information will be provided to you orally and followed in writing. If you do not respond before we must issue our final


decision letter, that decision will be based on the information in your appeal file.

Department of Managed Health Care Complaints The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan toll free at 1-800-464-4000 (TTY users call 1-800-777-1370 or 711) and use your health plan's grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department's Internet website http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.

Independent Medical Review (IMR) Except as described in this "Independent Medical Review (IMR)" section, you must exhaust our internal grievance procedure before you may request independent medical review unless we have failed to comply with the grievance procedure described under "Grievances" in this "Dispute Resolution" section. If you qualify, you or your authorized representative may have your issue reviewed through the Independent Medical Review (IMR) process managed by the California Department of Managed Health Care. The Department of Managed Health Care determines which cases qualify for IMR. This review is at no cost to you. If you decide not to request an IMR, you may give up the right to pursue some legal actions against us.

You may qualify for IMR if all of the following are true: • One of these situations applies to you:

♦ you have a recommendation from a provider requesting Medically Necessary Services

♦ you have received Emergency Services, emergency ambulance Services, or Urgent Care from a provider who determined the Services to be Medically Necessary

♦ you have been seen by a Plan Provider for the diagnosis or treatment of your medical condition

• Your request for payment or Services has been denied, modified, or delayed based in whole or in part on a decision that the Services are not Medically Necessary

• You have filed a grievance and we have denied it or we haven't made a decision about your grievance within 30 days (or three days for urgent grievances). The Department of Managed Health Care (DMHC) may waive the requirement that you first file a grievance with us in extraordinary and compelling cases, such as severe pain or potential loss of life, limb, or major bodily function. If we have denied your grievance, you must submit your request for an IMR within 6 months of the date of our written denial. However, the DMHC may accept your request after 6 months if they determine that circumstances prevented timely submission

You may also qualify for IMR if the Service you requested has been denied on the basis that it is experimental or investigational as described under "Experimental or investigational denials."

If the Department of Managed Health Care determines that your case is eligible for IMR, it will ask us to send your case to the Department of Managed Health Care's Independent Medical Review organization. The Department of Managed Health Care will promptly notify you of its decision after it receives the Independent Medical Review organization's determination. If the decision is in your favor, we will contact you to arrange for the Service or payment.

Experimental or investigational denials If we deny a Service because it is experimental or investigational, we will send you our written explanation within three days after we received your request. We will explain why we denied the Service and provide additional dispute resolution options. Also, we will provide information about your right to request Independent Medical Review if we had the following information when we made our decision:


• Your treating physician provided us a written statement that you have a life-threatening or seriously debilitating condition and that standard therapies have not been effective in improving your condition, or that standard therapies would not be appropriate, or that there is no more beneficial standard therapy we cover than the therapy being requested. "Life-threatening" means diseases or conditions where the likelihood of death is high unless the course of the disease is interrupted, or diseases or conditions with potentially fatal outcomes where the end point of clinical intervention is survival. "Seriously debilitating" means diseases or conditions that cause major irreversible morbidity

• If your treating physician is a Plan Physician, he or she recommended a treatment, drug, device, procedure, or other therapy and certified that the requested therapy is likely to be more beneficial to you than any available standard therapies and included a statement of the evidence relied upon by the Plan Physician in certifying his or her recommendation

• You (or your Non–Plan Physician who is a licensed, and either a board-certified or board-eligible, physician qualified in the area of practice appropriate to treat your condition) requested a therapy that, based on two documents from the medical and scientific evidence, as defined in California Health and Safety Code Section 1370.4(d), is likely to be more beneficial for you than any available standard therapy. The physician's certification included a statement of the evidence relied upon by the physician in certifying his or her recommendation. We do not cover the Services of the Non–Plan Provider

Note: You can request IMR for experimental or investigational denials at any time without first filing a grievance with us.

Additional Review You may have a right to request review in state court if you remain dissatisfied after you have exhausted our internal claims and appeals procedure, and if applicable, external review.

Binding Arbitration For all claims subject to this "Binding Arbitration" section, both Claimants and Respondents give up the right to a jury or court trial and accept the use of binding arbitration. Insofar as this "Binding Arbitration" section applies to claims asserted by Kaiser Permanente Parties,

it shall apply retroactively to all unresolved claims that accrued before the effective date of this Membership Agreement and Evidence of Coverage. Such retroactive application shall be binding only on the Kaiser Permanente Parties.

Scope of arbitration Any dispute shall be submitted to binding arbitration if all of the following requirements are met:

• The claim arises from or is related to an alleged violation of any duty incident to or arising out of or relating to this Membership Agreement and Evidence of Coverage or a Member Party's relationship to Kaiser Foundation Health Plan, Inc. (Health Plan), including any claim for medical or hospital malpractice (a claim that medical services or items were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered), for premises liability, or relating to the coverage for, or delivery of, services or items, irrespective of the legal theories upon which the claim is asserted

• The claim is asserted by one or more Member Parties against one or more Kaiser Permanente Parties or by one or more Kaiser Permanente Parties against one or more Member Parties

• Governing law does not prevent the use of binding arbitration to resolve the claim

Members enrolled under this Membership Agreement and Evidence of Coverage thus give up their right to a court or jury trial, and instead accept the use of binding arbitration except that the following types of claims are not subject to binding arbitration: • Claims within the jurisdiction of the Small Claims

Court • Claims subject to a Medicare appeal procedure as

applicable to Kaiser Permanente Senior Advantage Members

• Claims that cannot be subject to binding arbitration under governing law

As referred to in this "Binding Arbitration" section, "Member Parties" include:

• A Member

• A Member's heir, relative, or personal representative

• Any person claiming that a duty to him or her arises from a Member's relationship to one or more Kaiser Permanente Parties

"Kaiser Permanente Parties" include:

• Kaiser Foundation Health Plan, Inc.


• Kaiser Foundation Hospitals

• KP Cal, LLC

• The Permanente Medical Group, Inc.

• Southern California Permanente Medical Group

• The Permanente Federation, LLC

• The Permanente Company, LLC

• Any Southern California Permanente Medical Group or The Permanente Medical Group physician

• Any individual or organization whose contract with any of the organizations identified above requires arbitration of claims brought by one or more Member Parties

• Any employee or agent of any of the foregoing

"Claimant" refers to a Member Party or a Kaiser Permanente Party who asserts a claim as described above. "Respondent" refers to a Member Party or a Kaiser Permanente Party against whom a claim is asserted.

Rules of Procedure Arbitrations shall be conducted according to the Rules for Kaiser Permanente Member Arbitrations Overseen by the Office of the Independent Administrator ("Rules of Procedure") developed by the Office of the Independent Administrator in consultation with Kaiser Permanente and the Arbitration Oversight Board. Copies of the Rules of Procedure may be obtained from our Member Service Contact Center.

Initiating arbitration Claimants shall initiate arbitration by serving a Demand for Arbitration. The Demand for Arbitration shall include the basis of the claim against the Respondents; the amount of damages the Claimants seek in the arbitration; the names, addresses, and telephone numbers of the Claimants and their attorney, if any; and the names of all Respondents. Claimants shall include in the Demand for Arbitration all claims against Respondents that are based on the same incident, transaction, or related circumstances.

Serving Demand for Arbitration Health Plan, Kaiser Foundation Hospitals, KP Cal, LLC, The Permanente Medical Group, Inc., Southern California Permanente Medical Group, The Permanente Federation, LLC, and The Permanente Company, LLC, shall be served with a Demand for Arbitration by mailing the Demand for Arbitration addressed to that Respondent in care of:

For Northern California Members: Kaiser Foundation Health Plan, Inc. Legal Department 1950 Franklin St., 17th Floor Oakland, CA 94612

For Southern California Members: Kaiser Foundation Health Plan, Inc. Legal Department 393 E. Walnut St. Pasadena, CA 91188

Service on that Respondent shall be deemed completed when received. All other Respondents, including individuals, must be served as required by the California Code of Civil Procedure for a civil action.

Filing fee The Claimants shall pay a single, nonrefundable filing fee of $150 per arbitration payable to "Arbitration Account" regardless of the number of claims asserted in the Demand for Arbitration or the number of Claimants or Respondents named in the Demand for Arbitration.

Any Claimant who claims extreme hardship may request that the Office of the Independent Administrator waive the filing fee and the neutral arbitrator's fees and expenses. A Claimant who seeks such waivers shall complete the Fee Waiver Form and submit it to the Office of the Independent Administrator and simultaneously serve it upon the Respondents. The Fee Waiver Form sets forth the criteria for waiving fees and is available by calling our Member Service Contact Center.

Number of arbitrators The number of arbitrators may affect the Claimants' responsibility for paying the neutral arbitrator's fees and expenses (see the Rules of Procedure).

If the Demand for Arbitration seeks total damages of $200,000 or less, the dispute shall be heard and determined by one neutral arbitrator, unless the parties otherwise agree in writing that the arbitration shall be heard by two party arbitrators and one neutral arbitrator. The neutral arbitrator shall not have authority to award monetary damages that are greater than $200,000.

If the Demand for Arbitration seeks total damages of more than $200,000, the dispute shall be heard and determined by one neutral arbitrator and two party arbitrators, one jointly appointed by all Claimants and one jointly appointed by all Respondents. Parties who are entitled to select a party arbitrator may agree to waive this right. If all parties agree, these arbitrations will be heard by a single neutral arbitrator.


Payment of arbitrators' fees and expenses Health Plan will pay the fees and expenses of the neutral arbitrator under certain conditions as set forth in the Rules of Procedure. In all other arbitrations, the fees and expenses of the neutral arbitrator shall be paid one-half by the Claimants and one-half by the Respondents.

If the parties select party arbitrators, Claimants shall be responsible for paying the fees and expenses of their party arbitrator and Respondents shall be responsible for paying the fees and expenses of their party arbitrator.

Costs Except for the aforementioned fees and expenses of the neutral arbitrator, and except as otherwise mandated by laws that apply to arbitrations under this "Binding Arbitration" section, each party shall bear the party's own attorneys' fees, witness fees, and other expenses incurred in prosecuting or defending against a claim regardless of the nature of the claim or outcome of the arbitration.

General provisions A claim shall be waived and forever barred if (1) on the date the Demand for Arbitration of the claim is served, the claim, if asserted in a civil action, would be barred as to the Respondent served by the applicable statute of limitations, (2) Claimants fail to pursue the arbitration claim in accord with the Rules of Procedure with reasonable diligence, or (3) the arbitration hearing is not commenced within five years after the earlier of (a) the date the Demand for Arbitration was served in accord with the procedures prescribed herein, or (b) the date of filing of a civil action based upon the same incident, transaction, or related circumstances involved in the claim. A claim may be dismissed on other grounds by the neutral arbitrator based on a showing of a good cause. If a party fails to attend the arbitration hearing after being given due notice thereof, the neutral arbitrator may proceed to determine the controversy in the party's absence.

The California Medical Injury Compensation Reform Act of 1975 (including any amendments thereto), including sections establishing the right to introduce evidence of any insurance or disability benefit payment to the patient, the limitation on recovery for non-economic losses, and the right to have an award for future damages conformed to periodic payments, shall apply to any claims for professional negligence or any other claims as permitted or required by law.

Arbitrations shall be governed by this "Binding Arbitration" section, Section 2 of the Federal Arbitration Act, and the California Code of Civil Procedure provisions relating to arbitration that are in effect at the

time the statute is applied, together with the Rules of Procedure, to the extent not inconsistent with this "Binding Arbitration" section. In accord with the rule that applies under Sections 3 and 4 of the Federal Arbitration Act, the right to arbitration under this "Binding Arbitration" section shall not be denied, stayed, or otherwise impeded because a dispute between a Member Party and a Kaiser Permanente Party involves both arbitrable and nonarbitrable claims or because one or more parties to the arbitration is also a party to a pending court action with a third party that arises out of the same or related transactions and presents a possibility of conflicting rulings or findings.

Termination of Membership

Your membership termination date is the first day you are not covered (for example, if your termination date is January 1, 2016, your last minute of coverage was at 11:59 p.m. on December 31, 2015). You will be billed as a non-Member for any Services you receive after your membership terminates. When your membership terminates, Health Plan and Plan Providers have no further liability or responsibility under this Membership Agreement and Evidence of Coverage, except as provided under "Payments after Termination" in this "Termination of Membership" section.

How You May Terminate Your Membership If you are enrolled through Covered California. Please contact Covered California for information about how to terminate your membership and the effective date of termination.

If you are enrolled directly with Kaiser Permanente. You may terminate your membership by sending written notice, signed by the Subscriber, to the address below. Your membership will terminate at 11:59 p.m. on the last day of the month in which we receive your notice. Also, you must include with your notice all amounts payable related to this Membership Agreement and Evidence of Coverage, including Premiums, for the period prior to your termination date.

Kaiser Foundation Health Plan, Inc. California Service Center P.O. Box 23127 San Diego, CA 92193-3127


Termination Due to Loss of Eligibility If you meet the eligibility requirements described under "Who Is Eligible" in the "Premiums, Eligibility, and Enrollment" section on the first day of a month, but later in that month you no longer meet those eligibility requirements, your membership will end at 11:59 p.m. on the last day of that month. For example, if you become ineligible on December 5, 2015, your termination date is January 1, 2016, and your last minute of coverage is at 11:59 p.m. on December 31, 2015.

Continuation of membership If you lose eligibility as a Dependent and want to remain a Health Plan member, you might be able to enroll in one of our plans for individuals and families as a subscriber. If you want your new individual plan coverage to be effective when your Dependent coverage ends, you must submit your application within the special enrollment period for enrolling in an individual plan due to loss of other coverage. Otherwise, you will have to wait until the next annual open enrollment period.

To request an application to enroll directly with us, please go to kp.org or call our Member Service Contact Center. For information about plans that are available through Covered California, see "Covered California" below.

Covered California U.S. citizens or legal residents of the U.S. can buy health care coverage from Covered California. This is California's health insurance marketplace (the Exchange). You may apply for help to pay for premiums and copayments but only if you buy coverage through Covered California. This financial assistance may be available if you meet certain income guidelines. To learn more about coverage that is available through Covered California, visit www.CoveredCA.com or call Covered California at 1-800-300-1506 (TTY users call 711).

Termination for Cause If you intentionally commit fraud in connection with membership, Health Plan, or a Plan Provider, we may terminate your membership immediately by sending written notice to the Subscriber; termination will be effective on the date we send the notice. Some examples of fraud include: • Misrepresenting eligibility information about you or a

Dependent • Presenting an invalid prescription or physician order

• Misusing a Kaiser Permanente ID card (or letting someone else use it)

• Giving us incorrect or incomplete material information. For example, you have entered into a Surrogacy Arrangement and you fail to send us the information we require under "Surrogacy arrangements" under "Reductions" in the "Exclusions, Limitations, Coordination of Benefits, and Reductions" section

• Failing to notify us of changes in family status or Medicare coverage that may affect your eligibility or benefits

After your first 24 months of individuals and families coverage, we may not terminate you for cause solely because you gave us incorrect or incomplete material information in your application for health coverage.

If we terminate your membership for cause, you will not be allowed to enroll in Health Plan in the future. We may also report criminal fraud and other illegal acts to the authorities for prosecution.

Termination for Nonpayment of Premiums If you do not pay your required Premiums by the due date, we may terminate your membership as described in this "Termination for Nonpayment of Premiums" section. If you intend to terminate your membership, be sure to notify us as described under "How You May Terminate Your Membership" in this "Termination of Membership" section, as you will be responsible for any Premiums billed to you unless you let us know before the first of the coverage month that you want us to terminate your coverage.

Your Premium payment for the upcoming coverage month is due on the first day of that month. If we do not receive full Premium payment on or before the first day of the coverage month, we will send a notice of nonreceipt of payment (a "Late Notice") to the Subscriber's address of record. This Late Notice will include the following information: • A statement that we have not received full Premium

payment and that we will terminate this Membership Agreement and Evidence of Coverage for nonpayment if we do not receive the required Premiums within 30 days after the date of the Late Notice

• The amount of Premiums that are due

• The specific date and time when the memberships of the Subscriber and all Dependents will end if we do not receive the required Premiums


If we terminate this Membership Agreement and Evidence of Coverage because we did not receive the required Premiums when due, your membership will end at 11:59 p.m. on the 30th day after the date of the Late Notice. Your coverage will continue during this 30 day grace period, but upon termination you will be responsible for paying all past due Premiums, including the Premiums for this grace period.

We will mail a Termination Notice to the Subscriber's address of record if we do not receive full Premium payment within 30 days after the date of the Late Notice. The Termination Notice will include the following information: • A statement that we have terminated this Membership

Agreement and Evidence of Coverage for nonpayment of Premiums

• The specific date and time when the memberships of the Subscriber and all Dependents ended

• The amount of Premiums that are due

• Information explaining whether or not the Subscriber can reinstate this Membership Agreement and Evidence of Coverage

• Your appeal rights

If we terminate your membership, you are still responsible for paying all amounts due.

Reinstatement after termination for nonpayment of Premiums If you are enrolled through Covered California. Persons terminated for nonpayment of Premiums may not enroll in Health Plan until the next open enrollment.

If you are enrolled directly with Kaiser Permanente. Persons terminated for nonpayment of Premiums may not enroll in Health Plan even after paying all amounts owed unless we approve the enrollment.

If we terminate this Membership Agreement and Evidence of Coverage for nonpayment of Premiums, we will permit reinstatement of this Membership Agreement and Evidence of Coverage three times during any 12-month period if we receive the amounts owed within 15 days of the date of the Termination Notice. We will not reinstate this Membership Agreement and Evidence of Coverage if you do not obtain reinstatement of your terminated Membership Agreement and Evidence of Coverage within the required 15 days, or if we terminate the Membership Agreement and Evidence of Coverage for nonpayment of Premiums more than three times in a 12-month period.

If we receive advance payment of the premium tax credit on your behalf If we receive advance payment of the premium tax credit on your behalf, then you are responsible for paying the portion of the monthly Premiums that equals the full Premiums minus the advance payment of the premium tax credit that we receive on your behalf for that month. If we do not receive your portion of the monthly Premiums on time, we will provide a three-month grace period if both of the following requirements are met: • We have previously received the full monthly

Premiums for you (including advance payment of the premium tax credit) for at least one month in the calendar year

• We receive or will receive advance payment of the premium tax credit on your behalf for the month for which we do not receive your portion of the Premiums on time

We will send written notice stating when the grace period begins. The notice will explain when Premiums are due and when your coverage will terminate if you do not pay your portion of all outstanding Premiums. If we do not receive your portion of all outstanding Premiums (including any Premiums for the grace period months that are already due on the date you make your payment) by the end of the grace period, we may terminate your membership so that it ends at 11:59 pm on the last day of the grace period.

Termination for Discontinuance of a Product or all Products We may terminate your membership if we discontinue offering this product as permitted or required by law. If we continue to offer other individual (nongroup) products, we may terminate your membership under this product by sending you written notice at least 90 days before the termination date. You will be able to enroll in any other product we are then offering in the individual (nongroup) market if you meet all eligibility requirements. Under the Affordable Care Act, individual plan coverage is available without medical review. The premiums and coverage under the other individual plan may differ from those under this Membership Agreement and Evidence of Coverage. If we discontinue offering all individual (nongroup) products, we may terminate your membership by sending you written notice at least 180 days before the termination date.


Payments after Termination If we terminate your membership for cause or for nonpayment, we will: • Within 30 days, refund any amounts we owe for

Premiums you paid after the termination date

• Pay you any amounts we have determined that we owe you for claims during your membership in accord with the "Emergency Services and Urgent Care" and "Dispute Resolution" sections

We will deduct any amounts you owe Health Plan or Plan Providers from any payment we make to you.

Appealing Membership Termination If you believe that we terminated your membership improperly, you may file a grievance to appeal the decision. Please refer to the "Grievances" in the "Dispute Resolution" section for information on how to file a grievance.

State Review of Membership Termination If you believe that we terminated your membership because of your ill health or your need for care, you may request a review of the termination by the California Department of Managed Health Care (please see "Department of Managed Health Care Complaints" in the "Dispute Resolution" section).

Miscellaneous Provisions

Administration of this Membership Agreement and Evidence of Coverage We may adopt reasonable policies, procedures, and interpretations to promote orderly and efficient administration of this Membership Agreement and Evidence of Coverage.

Advance directives The California Health Care Decision Law offers several ways for you to control the kind of health care you will receive if you become very ill or unconscious, including the following:

• A Power of Attorney for Health Care lets you name someone to make health care decisions for you when you cannot speak for yourself. It also lets you write down your own views on life support and other treatments

• Individual health care instructions let you express your wishes about receiving life support and other treatment. You can express these wishes to your doctor and have them documented in your medical chart, or you can put them in writing and have that included in your medical chart

To learn more about advance directives, including how to obtain forms and instructions, contact the Member Services Department at a Plan Facility. You can also refer to Your Guidebook for more information about advance directives.

Membership Agreement and Evidence of Coverage binding on Members By electing coverage or accepting benefits under this Membership Agreement and Evidence of Coverage, all Members legally capable of contracting, and the legal representatives of all Members incapable of contracting, agree to all provisions of this Membership Agreement and Evidence of Coverage.

Applications and statements You must complete any applications, forms, or statements that we request in our normal course of business or as specified in this Membership Agreement and Evidence of Coverage.

Assignment You may not assign this Membership Agreement and Evidence of Coverage or any of the rights, interests, claims for money due, benefits, or obligations hereunder without our prior written consent.

Attorney and advocate fees and expenses In any dispute between a Member and Health Plan, the Medical Group, or Kaiser Foundation Hospitals, each party will bear its own fees and expenses, including attorneys' fees, advocates' fees, and other expenses.

Claims review authority We are responsible for determining whether you are entitled to benefits under this Membership Agreement and Evidence of Coverage and we have the discretionary authority to review and evaluate claims that arise under this Membership Agreement and Evidence of Coverage. We conduct this evaluation independently by interpreting the provisions of this Membership Agreement and Evidence of Coverage. We may use medical experts to help us review claims. If coverage under this Membership Agreement and Evidence of Coverage is subject to the Employee Retirement Income Security Act (ERISA) claims procedure regulation (29 CFR 2560.503-1), then we are a "named claims fiduciary" to review


claims under this Membership Agreement and Evidence of Coverage.

Governing law Except as preempted by federal law, this Membership Agreement and Evidence of Coverage will be governed in accord with California law and any provision that is required to be in this Membership Agreement and Evidence of Coverage by state or federal law shall bind Members and Health Plan whether or not set forth in this Membership Agreement and Evidence of Coverage.

No waiver Our failure to enforce any provision of this Membership Agreement and Evidence of Coverage will not constitute a waiver of that or any other provision, or impair our right thereafter to require your strict performance of any provision.

Nondiscrimination We do not discriminate on the basis of age, race, ethnicity, color, national origin, cultural background, ancestry, language, religion, sex, gender identity, gender expression, sexual orientation, marital status, physical or mental disability, or genetic information.

Notices Our notices to you will be sent to the most recent address we have for the Subscriber, except that if the Subscriber has chosen to receive these membership agreement and evidence of coverage documents online we will notify the Subscriber at the most recent email address we have for the Subscriber when notices related to amendment of this Membership Agreement and Evidence of Coverage are posted on our website at kp.org. The Subscriber is responsible for notifying us of any change in address. Subscribers who move (or change their email address if the Subscriber has chosen to receive these membership agreement and evidence of coverage documents on our website) should call our Member Service Contact Center as soon as possible to give us their new address. If a Member does not reside with the Subscriber, he or she should contact our Member Service Contact Center to discuss alternate delivery options.

Other formats for Members with disabilities You can request a copy of this Membership Agreement and Evidence of Coverage in an alternate format (Braille, audio, electronic text file, or large print) by calling our Member Service Contact Center.

Overpayment recovery We may recover any overpayment we make for Services from anyone who receives such an overpayment or from

any person or organization obligated to pay for the Services.

Privacy practices Kaiser Permanente will protect the privacy of your protected health information. We also require contracting providers to protect your protected health information. Your protected health information is individually-identifiable information (oral, written, or electronic) about your health, health care services you receive, or payment for your health care. You may generally see and receive copies of your protected health information, correct or update your protected health information, and ask us for an accounting of certain disclosures of your protected health information.

We may use or disclose your protected health information for treatment, health research, payment, and health care operations purposes, such as measuring the quality of Services. We are sometimes required by law to give protected health information to others, such as government agencies or in judicial actions. We will not use or disclose your protected health information for any other purpose without your (or your representative's) written authorization, except as described in our Notice of Privacy Practices (see below). Giving us authorization is at your discretion.

This is only a brief summary of some of our key privacy practices. OUR NOTICE OF PRIVACY PRACTICES, WHICH PROVIDES ADDITIONAL INFORMATION ABOUT OUR PRIVACY PRACTICES AND YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION, IS AVAILABLE AND WILL BE FURNISHED TO YOU UPON REQUEST. To request a copy, please call our Member Service Contact Center. You can also find the notice at a Plan Facility or on our website at kp.org.

Public policy participation The Kaiser Foundation Health Plan, Inc., Board of Directors establishes public policy for Health Plan. A list


of the Board of Directors is available on our website at kp.org or from our Member Service Contact Center. If you would like to provide input about Health Plan public policy for consideration by the Board, please send written comments to:

Kaiser Foundation Health Plan, Inc. Office of Board and Corporate Governance Services One Kaiser Plaza, 19th Floor Oakland, CA 94612

Telephone access (TTY) If you are hearing or speech impaired and use a text telephone device (TTY, also known as TDD) to communicate by phone, you can use the California Relay Service by calling 711 if a dedicated TTY number is not available for the telephone number that you want to call.

Helpful Information

Your Guidebook to Kaiser Permanente Services (Your Guidebook)

Please refer to Your Guidebook for helpful information about your coverage, such as:

• The location of Plan Facilities in your area and the types of covered Services that are available from each facility

• How to use our Services and make appointments

• Hours of operation

• Appointments and advice phone numbers

Your Guidebook provides other important information, such as preventive care guidelines and your Member rights and responsibilities. Your Guidebook is subject to change and is periodically updated. You can get a copy of Your Guidebook by visiting our website at kp.org or by calling our Member Service Contact Center.

Online Tools and Resources Here are some tools and resources available on our website at kp.org: • A directory of Plan Facilities and Plan Physicians • Tools you can use to email your doctor's office, view

test results, refill prescriptions, and schedule routine appointments

• Health education resources • Appointments and advice phone numbers

How to Reach Us

Appointments If you need to make an appointment, please call us or visit our website:

Call The appointment phone number at a Plan Facility (refer to Your Guidebook or the facility directory on our website at kp.org for phone numbers)

Website kp.org for routine (non-urgent) appointments with your personal Plan Physician or another Primary Care Physician

Not sure what kind of care you need? If you need advice on whether to get medical care, or how and when to get care, we have licensed health care professionals available to assist you by phone 24 hours a day, 7 days a week:

Call The appointment or advice phone number at a Plan Facility (refer to Your Guidebook or the facility directory on our website at kp.org for phone numbers)

Member Services If you have questions or concerns about your coverage, how to obtain Services, or the facilities where you can receive care, you can reach us by calling, writing, or visiting our website:

Call 1-800-464-4000

1-800-788-0616 (Spanish)

1-800-757-7585 (Chinese dialects)

24 hours a day, seven days a week (except closed holidays, and closed after 5 p.m. the day after Thanksgiving, after 5 p.m. on Christmas Eve, and after 5 p.m. on New Year's Eve)

Interpreter services available during all business hours at no cost to you.

TTY 1-800-777-1370 or 711



Write Member Services Department at a Plan Facility (refer to Your Guidebook for addresses)

Website kp.org

Authorization for Post-Stabilization Care To request prior authorization for Post-Stabilization Care as described under "Emergency Services" in the "Emergency Services and Urgent Care" section:

Call 1-800-225-8883 or the notification telephone number on your Kaiser Permanente ID card

24 hours a day, seven days a week

TTY 711

24 hours a day, seven days a week

Help with claim forms for Emergency Services, Post-Stabilization Care, Out-of-Area Urgent Care, and emergency ambulance Services If you need a claim form to request payment or reimbursement for Services described in the "Emergency Services and Urgent Care" section or under "Ambulance Services" in the "Benefits and Your Cost Share" section, or if you need help completing the form, you can reach us by calling or by visiting our website.

Call 1-800-464-4000 or 1-800-390-3510


TTY 1-800-777-1370 or 711


Website kp.org

Submitting claims for Emergency Services, Post-Stabilization Care, Out-of-Area Urgent Care, and emergency ambulance Services If you need to submit a completed claim form for Services described in the "Emergency Services and Urgent Care" section or under "Ambulance Services" in the "Benefits and Your Cost Share" section, or if you

need to submit other information that we request about your claim, send it to our Claims Department:

Write For Northern California Members:

Kaiser Foundation Health Plan, Inc. Claims Department P.O. Box 12923 Oakland, CA 94604-2923

For Southern California Members:

Kaiser Foundation Health Plan, Inc. Claims Department P.O. Box 7004 Downey, CA 90242-7004

Payment Responsibility This "Payment Responsibility" section briefly explains who is responsible for payments related to the health care coverage described in this Membership Agreement and Evidence of Coverage. Payment responsibility is more fully described in other sections of the Membership Agreement and Evidence of Coverage as described below: • The Subscriber is responsible for paying Premiums

(refer to "Premiums" in the "Premiums, Eligibility, and Enrollment" section)

• You are responsible for paying your Cost Share for covered Services (refer to "Your Cost Share" in the "Benefits and Your Cost Share" section)

• If you receive Emergency Services, Post-Stabilization Care, or Out-of-Area Urgent Care from a Non–Plan Provider, or if you receive emergency ambulance Services, you must pay the provider and file a claim for reimbursement unless the provider agrees to bill us (refer to "Payment and Reimbursement" in the "Emergency Services and Urgent Care" section)

• If you receive Services from Non–Plan Providers that we did not authorize (other than Emergency Services, Post-Stabilization Care, Out-of-Area Urgent Care, or emergency ambulance Services) and you want us to pay for the care, you must submit a grievance (refer to "Grievances" in the "Dispute Resolution" section)

• If you have Medicare, we will coordinate benefits with the other coverage (refer to "Coordination of Benefits" in the "Exclusions, Limitations, Coordination of Benefits, and Reductions" section)

• In some situations, you or a third party may be responsible for reimbursing us for covered Services (refer to "Reductions" in the "Exclusions, Limitations, Coordination of Benefits, and Reductions" section)


• You must pay the full price for noncovered Services


2015 Pediatric Dental Services Amendment We cover certain dental services for your Eligible Pediatric Enrollees from birth up to age 19 through Delta Dental of California. Please read the following information so that you will know how to obtain dental services. You must obtain dental benefits from (or be referred for specialist services by) your assigned contract dentist. ADDITIONAL INFORMATION ABOUT YOUR PEDIATRIC DENTAL BENEFITS IS AVAILABLE BY CALLING THE DELTA DENTAL CUSTOMER SERVICE DEPARTMENT AT 800-589-4618, 5 a.m. - 6 p.m., PACIFIC TIME, MONDAY THROUGH FRIDAY. Delta Dental of California (“Delta Dental”) 17871 Park Plaza Drive, Suite 200 Cerritos, CA 90703 IMPORTANT: If you opt to receive dental services that are not covered Benefits under this plan, a Contract Dentist may charge you his or her usual and customary rate for those services. Prior to providing a patient with dental services that are not a covered Benefit, the Dentist should provide to the patient a treatment plan that includes each anticipated service to be provided and the estimated cost of each service.

Kaiser Permanente – Platinum 90 HMO Date: June 15, 2014

Introduction This document amends your Kaiser Foundation Health Plan, Inc. (Health Plan) Membership Agreement and Evidence of Coverage to add coverage for pediatric dental services as described in this Pediatric Dental Services Amendment (“Amendment”). All provisions of the Membership Agreement and Evidence of Coverage apply to coverage described in this document except for the following sections: • "How to Obtain Services" (except that the completion of services information in the "Contracts with Plan Providers"

section does apply to coverage described in this document) • "Plan Facilities" • "Emergency Services and Urgent Care" • "Benefits and Your Cost Share," except that the information under “Out-of-pocket maximum” in the “Benefits and Your

Cost Share” section does apply • “Post-Service Claims and Appeals” • “Dispute Resolution”

DeltaCare® USA product provides essential pediatric dental care through a convenient network of Contract Dentists in the State of California. The network, screened to ensure that standards of quality, access and safety are maintained, is composed of established dental professionals. When you visit your assigned Contract Dentist, you pay only the applicable Cost Share for Benefits up to the out-of-pocket maximum. See the “Benefits and Your Cost Share” section of your Membership Agreement and Evidence of Coverage for information about your out-of-pocket maximum. Health Plan contracts with Delta Dental of California (“Delta Dental”) to make the DeltaCare USA network of Contract Dentists available to you. You can obtain covered Benefits from your assigned Contract Dentist without a referral from a Plan Physician. Your Cost Share is due when you receive covered Benefits. These pediatric dental Benefits are for children from birth up to age 19 who meet the eligibility requirements specified in your Membership Agreement and Evidence of Coverage.

Definitions In addition to the terms defined in the "Definitions" section of your Health Plan Membership Agreement and Evidence of Coverage the following terms, when capitalized and used in any part of this Amendment have the following meanings: Benefits mean those pediatric dental Services that are provided under the terms of this Amendment and described in this document. Contract Dentist means a Dentist who provides services in general dentistry and who has agreed to provide Benefits under this Program. Contract Orthodontist means a Dentist who specializes in orthodontics and who has agreed to provide Benefits under this Program, which covers medically necessary orthodontics. Contract Specialist means a Dentist who provides Specialist Services and who has agreed to provide Benefits to Enrollees under this Program. Dentist means a duly licensed Dentist legally entitled to practice dentistry at the time and in the state or jurisdiction in which services are performed. Eligible Pediatric Enrollee means a person eligible for dental Benefits under this Amendment. Eligible Pediatric Enrollees are children from birth up to age 19 who meet the eligibility requirements in your Health Plan Membership Agreement and Evidence of Coverage.


Emergency Pediatric Dental Service means care provided by a Dentist to treat a dental condition which manifests as a symptom of sufficient severity, including severe pain, such that the absence of immediate attention could reasonably be expected by the Enrollee to result in either: 1) placing the Enrollee’s dental health in serious jeopardy, or 2) serious impairment to dental functions. Optional means any alternative procedure presented by the Contract Dentist that satisfies the same dental need as a covered procedure, is chosen by the Enrollee, and is subject to the limitations and exclusions of this Amendment. Out-of-Network means treatment by a Dentist who has not signed an agreement with Delta Dental to provide Benefits under the terms of this Amendment. Pediatric Enrollee means an Eligible Pediatric Enrollee enrolled to receive Benefits; may also be referred to as “Enrollee.” Preauthorization means the process by which Delta Dental determines if a procedure or treatment is a referable Benefit under the Enrollee’s pediatric dental Program. Program means the set of pediatric dental benefits provided under this Amendment to your Membership Agreement and Evidence of Coverage. Reasonable means that an Enrollee exercises prudent judgment in determining that a dental emergency exists and makes at least one attempt to contact his/her Contract Dentist to obtain Emergency Pediatric Dental Services and, in the event the Dentist is not available, makes at least one attempt to contact Delta Dental for assistance before seeking care from another Dentist. Special Health Care Need means a physical or mental impairment, limitation or condition that substantially interferes with an Enrollee’s ability to obtain Benefits. Examples of such a Special Health Care Need are 1) the Enrollee’s inability to obtain access to the assigned Contract Dentist’s facility because of a physical disability, and 2) the Enrollee’s inability to comply with the Contract Dentist’s instructions during examination or treatment because of physical disability or mental incapacity. Specialist Service means services performed by a Dentist who specializes in the practice of oral surgery, endodontics, periodontics, orthodontics (if medically necessary) or pediatric dentistry. Specialist Services must be preauthorized in writing by Delta Dental. Treatment in Progress means any single dental procedure, as defined by the CDT Code, that has been started while the Pediatric Enrollee was eligible to receive Benefits, and for which multiple appointments are necessary to complete the procedure whether or not the Enrollee continues to be eligible for Benefits under this Program. Examples include: teeth that have been prepared for crowns, root canals where a working length has been established, full or partial dentures for which an impression has been taken and orthodontics when bands have been placed and tooth movement has begun.

How to Obtain Pediatric Dental Services Upon enrollment, the Enrollee will be assigned to a Contract Dentist. The Enrollee may change his or her assigned Contract Dentist by directing a request to the Customer Service department at 800-589-4618. A list of Contract Dentists is available to all Enrollees at deltadentalins.com. Enrollees in the same family may collectively select no more than three Contract Dentist facilities. The change must be requested prior to the 21st of the month to become effective on the first day of the following month. Delta Dental will provide you written notice of assignment to another Contract Dentist facility near the Enrollee’s home, if 1) a selected facility is closed to further enrollment, 2) a chosen Contract Dentist withdraws from the DeltaCare USA network, or 3) an assigned facility requests, for good cause, that the Enrollee be re-assigned to another Contract Dentist. All Treatment in Progress must be completed before you change to another Contract Dentist. EACH ENROLLEE MUST GO TO HIS OR HER ASSIGNED CONTRACT DENTIST TO OBTAIN COVERED SERVICES.


All services which are Benefits shall be rendered at the Contract Dentist’s facility selected by the Enrollee. Delta Dental shall have no obligation or liability with respect to services rendered by Out-of Network Dentists, with the exception of Emergency Pediatric Dental Services or Specialist Services recommended by a Contract Dentist, and preauthorized in writing by Delta Dental. Any other treatment is not covered under this Program. A Contract Dentist may provide services either personally, or through associated Dentists, or the other technicians or hygienists who may lawfully perform the services. If an Enrollee is assigned to a dental school clinic for Specialist Services, those services may be provided by a Dentist, a dental student, a clinician or a dental instructor.

If your assigned Contract Dentist terminates participation in the DeltaCare USA network, that Contract Dentist will complete all Treatment in Progress as described above. If, for any reason, the Contract Dentist is unable to complete treatment, Delta Dental shall make reasonable and appropriate provisions for the completion of such treatment by another Contract Dentist.

Benefits, Limitations and Exclusions This Program provides the Benefits described in Schedule A subject to the limitations and exclusions described in Schedule B. Benefits are only available in the state of California. The services are performed as deemed appropriate by your attending Contract Dentist.

Emergency Pediatric Dental Services Your assigned Contract Dentist maintains a 24 hour Emergency Pediatric Dental Services system seven days a week. If Emergency Pediatric Dental Services are needed, you should contact the assigned Contract Dentist whenever possible. If a new Pediatric Enrollee needs Emergency Pediatric Dental Services, but does not have an assigned Contract Dentist yet, contact Delta Dental’s Customer Service department at 800-589-4618 for help in locating a Contract Dentist. Benefits for Emergency Pediatric Dental Services by an Out-of-Network Dentist are limited to necessary care to stabilize the Enrollee’s condition and/or provide palliative relief when you:

1) have made a Reasonable attempt to contact the Contract Dentist and the Contract Dentist is unavailable or the Enrollee cannot be seen within 24 hours of making contact; or

2) have made a Reasonable attempt to contact Delta Dental prior to receiving Emergency Pediatric Dental Services, or it is Reasonable for you to access Emergency Pediatric Dental Services without prior contact with Delta Dental; or

3) reasonably believe that the Enrollee’s condition makes it dentally/medically inappropriate to travel to the Contract Dentist to receive Emergency Pediatric Dental Services.

If the above conditions are not met, you are responsible for any charges for services by a provider other than the assigned Contract Dentist. Further treatment must be obtained from the assigned Contract Dentist. You are responsible for your Cost Share for any treatment received due to an emergency.

Specialist Services Specialist Services for oral surgery, endodontics, periodontics or pediatric dentistry, must be 1) referred by the assigned Contract Dentist, and 2) preauthorized in writing by Delta Dental. You pay the specified Cost Share. (Refer to Schedule A, Description of Benefits and Cost Share for Pediatric Benefits and Schedule B, Limitations and Exclusions of Benefits.)


If you require Specialist Services and there is no Contract Specialist to provide these services within 35 miles of your home address, the assigned Contract Dentist must receive written Preauthorization from Delta Dental to refer you to an Out-of-Network specialist to provide the Specialist Services. Specialist Services performed by an Out-of-Network specialist that are not authorized by Delta Dental may not be covered. If the services of a Contract Orthodontist are needed, please refer to Orthodontics in the Description of Benefits and Cost Share for Pediatric Benefits and Limitations and Exclusions of Benefits to determine which procedures are covered under this Program.

Claims for Reimbursement Claims for covered Emergency Pediatric Dental Services or preauthorized Specialist Services should be sent to Delta Dental within 90 days of the end of treatment. Valid claims received after the 90-day period will be reviewed if you can show that it was not reasonably possible to submit the claim within that time. The address for claims submission is Delta Dental Claims Department, P.O. Box 1810, Alpharetta, GA 30023.

Cost Share and Other Charges You are required to pay any Cost Share listed in Schedule A. Your Cost Share is paid directly to the Dentist who provides treatment. Charges for broken appointments (unless notice is received by the Dentist at least 24 hours in advance or an emergency prevented such notice), and charges for visits after normal visiting hours are listed in Schedule A. In the event that Delta Dental fails to pay a Contract Dentist, you will not be liable to that Dentist for any sums owed by Delta Dental. By statute, the DeltaCare USA provider contract contains a provision prohibiting a Contract Dentist from charging an Enrollee for any sums owed by Delta Dental. Except for the provisions in Emergency Pediatric Dental Services, if you have not received Preauthorization for treatment from an Out-of-Network Dentist, you may be liable to that Dentist for the cost of services. For further clarification, see Emergency Pediatric Dental Services and Specialist Services.

Second Opinion You may request a second opinion if you disagree with or question the diagnosis and/or treatment plan determination made by the Contract Dentist. You may also be requested to obtain a second opinion to verify the necessity and appropriateness of dental treatment or the application of Benefits. Second opinions will be rendered by a licensed Dentist in a timely manner, appropriate to the nature of the Enrollee’s condition. Requests involving cases of imminent and serious health threat will be expedited (authorization approved or denied within 72 hours of receipt of the request, whenever possible). For assistance or additional information regarding the procedures and timeframes for second opinion authorizations, contact the Customer Service department at 800-589-4618 or write to Delta Dental at P.O. Box 1810, Alpharetta, GA 30023. Second opinions will be provided at another Contract Dentist’s facility, unless otherwise authorized by Delta Dental. A second opinion by an Out-of-Network provider will be authorized if an appropriately qualified Contract Dentist is not available. Only second opinions which have been approved or authorized will be paid. You will be sent a written notification if your request for a second opinion is not authorized. If you disagree with this determination, you may file a grievance with Delta Dental. Refer to the Enrollee Complaint Procedure section for more information.

Special Needs If an Enrollee believes he or she has a Special Health Care Need, the Enrollee should contact Delta Dental’s Customer Service department at 800-589-4618. Delta Dental will confirm that a Special Health Care Need exists, and what arrangements can be made to assist the Enrollee in obtaining such Benefits. Delta Dental shall not be responsible for the failure of any Contract Dentist to comply with any law or regulation concerning structural office requirements that apply to a Dentist treating persons with Special Health Care Needs.


Facility Accessibility Many facilities provide information about special features of their offices, including accessibility information for patients with mobility impairments. To obtain information regarding facility accessibility, contact Delta Dental’s Customer Service department at 800-589-4618.

Provider Compensation A Contract Dentist is compensated by Delta Dental through monthly capitation (an amount based on the number of Enrollees assigned to the Dentist), and by Enrollees through required Cost Share for treatment received. A Contract Specialist is compensated by Delta Dental through an agreed-upon amount for each covered procedure, less the applicable Cost Share paid by the Enrollee. In no event does Delta Dental pay a Contract Dentist or a specialist any incentive as an inducement to deny, reduce, limit or delay any appropriate treatment. You may obtain further information concerning compensation by calling Delta Dental at 800-589-4618.

Processing Policies The dental care guidelines for the Program explain to Contract Dentists what services are covered under this Amendment. Contract Dentists will use their professional judgment to determine which services are appropriate for the Enrollee. Dental services performed by the Contract Dentist that fall under the scope of Benefits of the Program are provided subject to any Cost Share. If a Contract Dentist believes that an Enrollee should seek treatment from a specialist, the Contract Dentist contacts Delta Dental for a determination of whether the proposed treatment is a covered benefit. Delta Dental will also determine whether the proposed treatment requires treatment by a specialist. An Enrollee may contact Delta Dental’s Customer Service department at 800-589-4618 for information regarding the dental care guidelines for this Program

Enrollee Complaint Procedure Complaints regarding dental services:

Delta Dental or the Administrator shall provide notification if any dental services or claims are denied, in whole or in part, stating the specific reason or reasons for the denial. If you have any complaint regarding the denial of dental services or claims, the policies, procedures or operations of Delta Dental or the Administrator or the quality of dental services performed by a Contract Dentist, you may call the Customer Service Center at 800-589-4618, or the complaint may be addressed in writing to:

Quality Management Department

P.O. Box 6050

Artesia, CA 90702

Written communication must include: 1) the name of the patient; 2) the name, address, telephone number and ID number of the Pediatric Enrollee; and 3) the Dentist's name and facility location.

“Grievance” means a written or oral expression of dissatisfaction regarding the plan and/or provider, including quality of care concerns, and shall include a complaint, dispute, request for reconsideration or appeal made by Pediatric Enrollee or the Enrollee’s representative. Where the plan is unable to distinguish between a grievance and an inquiry, it shall be considered a grievance.

“Complaint” is the same as “grievance.”

“Complainant” is the same as “grievant” and means the person who filed the grievance including the Enrollee, a representative designated by the Enrollee, or other individual with authority to act on behalf of the Enrollee.

Within 5 calendar days of the receipt of any complaint, the quality management coordinator will forward to you an acknowledgment of receipt of the complaint. Certain complaints may require that you be referred to a Dentist for clinical evaluation of the dental services provided. We will forward to you a determination, in writing, within 30 days of receipt of


a complaint or shall provide a written explanation if additional time is required to report on the complaint. If the complaint involves severe pain and/or imminent and serious threat to a patient’s dental health, Delta Dental will provide the Enrollee written notification regarding the disposition or pending status of the grievance within three days.

If you have completed Delta Dental’s grievance process, or you have been involved in Delta Dental’s grievance procedure for more than 30 days, you may file a complaint with the California Department of Managed Health Care (“Department”). You may file a complaint with the Department immediately in an emergency situation, which is one involving severe pain and/or imminent and serious threat to the Enrollee’s health.

The Department is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone us, your plan, at 1-800-589-4618 and use our grievance process above before contacting the Department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assistance.

You may also be eligible for an Independent Medical Review (“IMR”). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The Department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The Department's Internet Website (http://www.hmohelp.ca.gov) has complaint forms, IMR application forms and instructions online.

Complaints Involving an Adverse Benefit Determination

For complaints involving an adverse benefit determination (e.g. a denial, modification or termination of a requested benefit or claim) the Enrollee must file a request for review (a complaint) with Delta Dental] within at least 180 days after receipt of the adverse determination. Our review will take into account all information, regardless of whether such information was submitted or considered initially. The review shall be conducted by a person who is neither the individual who made the original benefit determination, nor the subordinate of such individual. Upon request and free of charge, we will provide the Enrollee with copies of any pertinent documents that are relevant to the benefit determination, a copy of any internal rule, guideline, protocol, and/or explanation of the scientific or clinical judgment if relied upon in making the benefit determination. If the review of a denial is based in whole or in part on a lack of medical necessity, experimental treatment, or a clinical judgment in applying the terms of the Contract, Delta Dental shall consult with a Dentist who has appropriate training and experience. If any consulting Dentist is involved in the review, the identity of such consulting Dentist will be available upon request.

Complaints regarding all other issues:

If you have any other type of complaint or grievance, you can file a grievance with Health Plan. Your grievance must explain your issue, such as the reasons why you believe a decision was in error or why you are dissatisfied about Services you received. You may submit your grievance orally or in writing to Health Plan as described in the "Dispute Resolution" section of your Membership Agreement and Evidence of Coverage.


SCHEDULE A - Description of Benefits and Cost Share for Pediatric Benefits (Under Age 19) The Benefits shown below are performed as needed and deemed appropriate by the attending Contract Dentist subject to the limitations and exclusions of the Program. Please refer to Schedule B for further clarification of Benefits. Enrollees should discuss all treatment options with their Contract Dentist prior to services being rendered. Text that appears in italics below is specifically intended to clarify the delivery of Benefits under the DeltaCare® USA plan and is not to be interpreted as CDT-2014 procedure codes, descriptors or nomenclature which is under copyright by the American Dental Association. The American Dental Association may periodically change CDT codes or definitions. Such updated codes, descriptors and nomenclature may be used to describe these covered procedures in compliance with federal legislation.

Code Description Pediatric Enrollee Pays

Clarifications/Limitations

D0100–D0999 I. DIAGNOSTIC D0999 Unspecified diagnostic procedure -- by report No Cost Includes office visit, per visit (in addition

to other services) D0120 Periodic oral evaluation -- established patient No Cost D0140 Limited oral evaluation -- problem focused No Cost D0145 Oral evaluation for a patient under three year

of age and counseling with primary caregiver No Cost

D0150 Comprehensive oral evaluation -- new or established patient

No Cost

D0160 Detailed and extensive oral evaluation, problem focused, by report

No Cost

D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit)

No Cost

D0180 Comprehensive periodontal evaluation – new or established patient

No Cost

D0190 Screening of a patient No Cost D0191 Assessment of a patient No Cost D0210 Intraoral - complete series of radiographic

images No Cost Limited to 1 every 24 consecutive

months D0220 Intraoral - periapical first radiographic image No Cost D0230 Intraoral - periapical each additional

radiographic image No Cost

D0240 Intraoral - occlusal radiographic image No Cost D0270 Bitewing - single radiographic image No Cost D0272 Bitewings - two radiographic images No Cost D0273 Bitewings - three radiographic images No Cost D0274 Bitewings - four radiographic images No Cost D0277 Vertical bitewings - 7 to 8 radiographic images No Cost D0330 Panoramic radiographic image No Cost Limited to 1 every 24 consecutive

months D0460 Pulp vitality tests No Cost D0470 Diagnostic casts No Cost




D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report

No Cost

D0601 Caries risk assessment and documentation, with a finding of low risk

No Cost

D0602 Caries risk assessment and documentation, with a finding of moderate risk

No Cost

D0603 Caries risk assessment and documentation, with a finding of high risk

No Cost

D1000-D1999 II. PREVENTIVE D1110 Prophylaxis - adult No Cost Cleaning; 2 per 12 month period D1120 Prophylaxis - child No Cost Cleaning; 2 per 12 month period D1206 Topical application of fluoride varnish No Cost 2 per 12 month period D1208 Topical application of fluoride No Cost 2 per 12 month period D1310 Nutritional counseling for control of dental

disease No Cost

D1330 Oral hygiene instructions No Cost D1351 Sealant - per tooth No Cost Limited to permanent first and second

molars without restorations or decay D1352 Preventive resin restoration in a moderate to

high caries risk patient – permanent tooth No Cost Limited to permanent first and second

molars without restorations or decay D1510 Space maintainer - fixed - unilateral No Cost D1515 Space maintainer - fixed - bilateral No Cost D1520 Space maintainer - removable - unilateral No Cost D1525 Space maintainer - removable - bilateral No Cost D1550 Re-cementation of space maintainer No Cost D1555 Removal of fixed space maintainer No Cost Included in case by Dentist who placed

appliance D2000-D2999 III. RESTORATIVE - Includes polishing, all adhesives and bonding agents, indirect pulp capping, bases, liners and acid etch procedures. D2140 Amalgam - one surface, primary or permanent $25 D2150 Amalgam - two surfaces, primary or

permanent $105

D2160 Amalgam - three surfaces, primary or permanent

$110

D2161 Amalgam - four or more surfaces, primary or permanent

$115

D2330 Resin-based composite - one surface, anterior $115 D2331 Resin-based composite - two surfaces,

anterior $120

D2332 Resin-based composite - three surfaces, anterior

$135

D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior)

$165

D2390 Resin-based composite crown, anterior $200 D2543 Onlay - metallic - three surfaces $350 D2544 Onlay - metallic - four or more surfaces $350 D2710 Crown - resin-based composite (indirect) $350




D2740 Crown - porcelain/ceramic substrate $350 D2750 Crown - porcelain fused to high noble metal $350 D2751 Crown - porcelain fused to predominantly

base metal $300

D2752 Crown - porcelain fused to noble metal $350 D2780 Crown - 3/4 cast high noble metal $350 D2781 Crown - 3/4 cast predominantly base metal $350 D2782 Crown - 3/4 cast noble metal $350 D2783 Crown - 3/4 porcelain/ceramic $350 D2790 Crown - full cast high noble metal $350 D2791 Crown - full cast predominantly base metal $350 D2792 Crown - full cast noble metal $350 D2910 Recement inlay, onlay, or partial coverage

restoration $65

D2915 Recement cast or prefabricated post and core $65 D2920 Recement crown $65 D2929 Prefabricated porcelain/ceramic crown –

primary tooth No Cost Anterior tooth

D2930 Prefabricated stainless steel crown – primary tooth

$200

D2931 Prefabricated stainless steel crown - permanent tooth

$170

D2932 Prefabricated resin crown $170 When not used in conjunction with any other crown; anterior tooth

D2933 Prefabricated stainless steel crown with resin window

$150

D2934 Prefabricated esthetic coated stainless steel crown - primary tooth

$160

D2940 Protective restoration $30 D2950 Core buildup, including any pins when

required $120

D2951 Pin retention - per tooth, in addition to restoration

$40

D2952 Post and core in addition to crown, indirectly fabricated

$160 Base metal post; includes canal preparation

D2954 Prefabricated post and core in addition to crown

$140 Includes canal preparation

D2955 Post removal $130 D2970 Temporary crown (fractured tooth) $170 D2980 Crown repair necessitated by restorative

material failure $130

D2981 Inlay repair necessitated by restorative material failure

No Cost

D2982 Onlay repair necessitated by restorative material failure

No Cost

D2990 Resin infiltration of incipient smooth surface lesions

No Cost




D3000-D3999 IV. ENDODONTICS D3110 Pulp cap - direct (excluding final restoration) $40 D3120 Pulp cap - indirect (excluding final restoration) $45 D3220 Therapeutic pulpotomy (excluding final

restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament

$85

D3221 Pulpal debridement, primary and permanent teeth

$90

D3222 Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development

$120

D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration)

$120

D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration)

$110

D3310 Endodontic therapy, anterior tooth (excluding final restoration)

$300 Root canal; per canal

D3320 Endodontic therapy, bicuspid tooth (excluding final restoration)


D3330 Endodontic therapy, molar (excluding final restoration)


D3346 Retreatment of previous root canal therapy - anterior

$350 Per canal

D3347 Retreatment of previous root canal therapy - bicuspid

$350 Per canal

D3348 Retreatment of previous root canal therapy - molar

$350 Per canal

D3351 Apexification/recalcification – initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.)

$140

D3352 Apexification/recalcification – interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.)

$140

D3353 Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.)

$220

D3410 Apicoectomy - anterior $350 Per canal D3421 Apicoectomy - bicuspid (first root) $350 Per canal D3425 Apicoectomy - molar (first root) $350 Per canal D3426 Apicoectomy (each additional root) $150 Per canal D3427 Periradicular surgery without apicoectomy $350 Per canal D3430 Retrograde filling - per root $120 D3450 Root amputation - per root $170




D4000-D4999 V. PERIODONTICS D4210 Gingivectomy or gingivoplasty - four or more

contiguous teeth or tooth bounded spaces per quadrant

$150

D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant

$150

D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth

No Cost

D4240 Gingival flap procedure, including root planning - four or more contiguous teeth or tooth bounded spaces per quadrant

$350

D4241 Gingival flap procedure, including root planning - one to three contiguous teeth or tooth bounded spaces per quadrant

$280

D4260 Osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant

$350

D4261 Osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant

$350

D4341 Periodontal scaling and root planing - four or more teeth per quadrant

$115

D4342 Periodontal scaling and root planing - one to three teeth per quadrant

$85

D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis

$70

D4920 Unscheduled dressing change (by someone other than treating dentist or their staff)

$50

D5000-D5899 VI. PROSTHODONTICS (removable) D5110 Complete denture - maxillary $350 D5120 Complete denture - mandibular $350 D5130 Immediate denture - maxillary $350 D5140 Immediate denture - mandibular $350 D5211 Maxillary partial denture - resin base (including

any conventional clasps, rests and teeth) $350

D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth)

$350

D5213 Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)

$350

D5214 Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)

$350

D5281 Removable unilateral partial denture – one piece cast metal (including clasps and teeth)

$350

D5410 Adjust complete denture - maxillary $50 D5411 Adjust complete denture - mandibular $50 D5421 Adjust partial denture - maxillary $45 D5422 Adjust partial denture - mandibular $50




D5510 Repair broken complete denture base $100 D5520 Replace missing or broken teeth – complete

denture (each tooth) $80

D5610 Repair resin denture base $100 D5620 Repair cast framework $130 D5630 Repair or replace broken clasp $110 D5640 Replace broken teeth - per tooth $90 D5650 Add tooth to existing partial denture $100 D5660 Add clasp to existing partial denture $120 D5710 Rebase complete maxillary denture $350 D5711 Rebase complete mandibular denture $350 D5720 Rebase maxillary partial denture $305 D5721 Rebase mandibular partial denture $305 D5730 Reline complete maxillary denture (chairside) $210 D5731 Reline complete mandibular denture

(chairside) $210

D5740 Reline maxillary partial denture (chairside) $195 D5741 Reline mandibular partial denture (chairside) $195 D5750 Reline complete maxillary denture (laboratory) $210 D5751 Reline complete mandibular denture

(laboratory) $210

D5760 Reline maxillary partial denture (laboratory) $210 D5761 Reline mandibular partial denture (laboratory) $210 D5850 Tissue conditioning, maxillary $100 D5851 Tissue conditioning, mandibular $100 D5900-D5999 VII. MAXILLOFACIAL PROSTHETICS - Not Covered D6000-D6199 VIII. IMPLANT SERVICES - Not Covered D6200-D6999 IX. PROSTHODONTICS, fixed - Each retainer and each pontic constitutes a unit in a fixed partial denture (bridge) D6210 Pontic - cast high noble metal $350 D6211 Pontic - cast predominantly base metal $350 D6212 Pontic - cast noble metal $350 D6214 Pontic - titanium $350 Excluding molars D6240 Pontic - porcelain fused to high noble metal $300 D6241 Pontic - porcelain fused to predominantly base

metal $350

D6242 Pontic - porcelain fused to noble metal $350 D6610 Onlay - cast high noble metal, two surfaces $350 D6611 Onlay - cast high noble metal, three or more

surfaces $350

D6612 Onlay - cast predominantly base metal, two surfaces

$350

D6613 Onlay - cast predominantly base metal, three or more surfaces

$350

D6614 Onlay - cast noble metal, two surfaces $350 D6615 Onlay - cast noble metal, three or more

surfaces $350




D6740 Crown - porcelain/ceramic $350 D6750 Crown - porcelain fused to high noble metal $350 D6751 Crown - porcelain fused to predominantly base

metal $300

D6752 Crown - porcelain fused to noble metal $350 D6780 Crown - 3/4 cast high noble metal $350 D6781 Crown - 3/4 cast predominantly base metal $350 D6782 Crown - 3/4 cast noble metal $350 D6783 Crown - 3/4 porcelain/ceramic $350 D6790 Crown - full cast high noble metal $350 D6791 Crown - full cast predominantly base metal $350 D6792 Crown - full cast noble metal $350 D6794 Crown - titanium $350 D6930 Recement fixed partial denture $80 D6940 Stress breaker $138 D6980 Fixed partial denture repair necessitated by

restorative material failure $200

D7000-D7999 X. ORAL AND MAXILLOFACIAL SURGERY - Includes preoperative evaluations and treatment under a local anesthetic. Postoperative services include exams, suture removal and treatment of complications. D7140 Extraction, erupted tooth or exposed root

(elevation and/or forceps removal) $65

D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated

$165

D7220 Removal of impacted tooth - soft tissue $225 D7230 Removal of impacted tooth - partially bony $180 D7240 Removal of impacted tooth - completely bony $160 D7241 Removal of impacted tooth - completely bony,

with unusual surgical complications $300

D7250 Surgical removal of residual tooth roots (cutting procedure)

$165

D7285 Biopsy of oral tissue - hard (bone, tooth) $197 D7286 Biopsy of oral tissue - soft $180 D7310 Alveoloplasty in conjunction with extractions -

four or more teeth or tooth spaces, per quadrant

$160

D7311 Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant

$130

D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant

$180

D7321 Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant

$160

D7410 Excision of benign lesion up to 1.25 cm $175 D7411 Excision of benign lesion greater than 1.25 cm $225




D7412 Excision of benign lesion, complicated $325 D7450 Removal of benign odontogenic cyst or tumor -

lesion diameter up to 1.25 cm $160

D7451 Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm

$300

D7460 Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm

$141

D7461 Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm

$228

D7471 Removal of lateral exostosis (maxilla or mandible)

$350

D7472 Removal of torus palatinus $350 D7473 Removal of torus mandibularis $350 D7510 Incision and drainage of abscess – intraoral

soft tissue $110

D7511 Incision and drainage of abscess – intraoral soft tissue - complicated (includes drainage of multiple fascial spaces)

$170

D7520 Incision and drainage of abscess – extraoral soft tissue

$180

D7521 Incision and drainage of abscess – extraoral soft tissue - complicated (includes drainage of multiple fascial spaces)

$225

D7910 Suture of recent small wounds up to 5 cm $150 D7911 Complicated suture - up to 5 cm $205 D7912 Complicated suture - greater than 5 cm $300 D7960 Frenulectomy - also known as frenectomy or

frenotomy - separate procedure not incidental to another procedure

$250

D7963 Frenuloplasty $200 D8000-D8999 XI. ORTHODONTICS - Medically Necessary - Orthodontic Services must meet medical necessity as determined by a dentist. Orthodontic treatment is a benefit only when medically necessary as evidenced by a severe handicapping malocclusion and when a prior authorization is obtained. Severe handicapping malocclusion is not a cosmetic condition. Teeth must be severely misaligned causing functional problems that compromise oral and/or general health.

- Comprehensive orthodontic treatment procedure (D8080) includes all appliances, adjustments, insertion, removal and post treatment stabilization (retention). The Enrollee must continue to be eligible during active treatment. No additional charge to the Enrollee is permitted from the original treating orthodontist or dental office who received the comprehensive case fee. A separate fee applies for services provided by an orthodontist other than the original treating orthodontist or dental office. - Refer to Schedule B for additional information on Medically Necessary Orthodontics.

Pre-treatment Records after Approved Referral for Thumb Sucking or Tongue Thrust Appliance: D0220 Intraoral - periapical first radiographic image No Cost Anterior only of the affected arch; for

orthodontic records only D0230 Intraoral - periapical each additional

radiographic image No Cost Anterior only of the affected arch; for

orthodontic records only




Pre-treatment Records after Approved Referral for Evaluation of Handicapping Malocclusion: D0350 Oral/facial photographic images No Cost Limited to images with and as a part of a

covered pre-orthodontic treatment visit D0470 Diagnostic casts No Cost Pre-treatment Records with Plan Prior Approval for Comprehensive Orthodontics: D0210 Intraoral - complete series of radiographic

images No Cost For covered orthodontic records only

D0322 Tomographic survey $100 Only with documentation of medical necessity for cleft palates or craniofacial anomalies

D0340 Cephalometric radiographic image $35 Post-treatment Records after Completion of Covered Comprehensive Orthodontics: D0210 Intraoral - complete series of radiographic

images No Cost For covered orthodontic records only

D0340 Cephalometric radiographic image $35 Only with documentation of medical necessity for cleft palates or craniofacial anomalies

D0350 Oral/facial photographic images No Cost Limited to images with and as a part of a covered pre-orthodontic treatment visit

D0470 Diagnostic casts No Cost D8050 Interceptive orthodontic treatment of the

primary dentition $1,000 Limited to Enrollee with a qualifying

handicapping malocclusion and a cleft palate or craniofacial anomaly

D8060 Interceptive orthodontic treatment of the transitional dentition

$1,000 Limited to Enrollee with a qualifying handicapping malocclusion and a cleft palate or craniofacial anomaly

D8080 Comprehensive orthodontic treatment of the adolescent dentition

$1,000

D8210 Removable appliance therapy $300 D8220 Fixed appliance therapy $350 D8660 Pre-orthodontic treatment visit $75 D8670 Periodic orthodontic treatment visit (as part of

contract) $75 Included in the orthodontic case fee

D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s))

$250 Removable retainer(s); included in the orthodontic case fee; a separate fee applies for services provided by an orthodontist other than the original treating orthodontist or dental office who was paid for banding

D8691 Repair of orthodontic appliance $105 D8692 Replacement of lost or broken retainer $150 D8693 Rebonding or recementing of fixed retainers $68 D8694 Repair of fixed retainers, includes

reattachment $68

D9000-D9999 XII. ADJUNCTIVE GENERAL SERVICES D9110 Palliative (emergency) treatment of dental

pain - minor procedure $55




D9215 Local anesthesia in conjunction with operative or surgical procedures

$35

D9220 Deep sedation/general anesthesia - first 30 minutes

$225 Covered only when given by a Contract Dentist for covered oral surgery

D9221 Deep sedation/general anesthesia – each additional 15 minutes


D9230 Inhalation of nitrous oxide / anxiolysis, analgesia

$45 Per 30 minute increment (where available)

D9241 Intravenous conscious sedation/analgesia - first 30 minutes


D9242 Intravenous conscious sedation/analgesia - each additional 15 minutes


D9248 Non-intravenous conscious sedation $120 Where available D9310 Consultation - diagnostic service provided by

dentist or physician other than requesting dentist or physician

$75

D9430 Office visit for observation (during regularly scheduled hours) - no other services performed

No Cost

D9440 Office visit - after regularly scheduled hours $75 D9930 Treatment of complications (post-surgical) -

unusual circumstances, by report $90

D9999 Unspecified adjunctive procedure, by report $50 Includes failed appointment without 24 hour notice


Endnotes: Base metal is the benefit. If noble or high noble metal (precious) is used for a crown, bridge, indirectly fabricated post and core, inlay or onlay, the Enrollee will be charged the additional laboratory cost of the noble or high noble metal. If covered, an additional laboratory charge also applies to a titanium crown. Porcelain/ceramic crown, pontic and fixed bridge retainer on molars is considered a material upgrade with a maximum additional charge to the Enrollee of $150 per unit. For a covered porcelain-fused-to-metal crown or pontic, a porcelain margin is considered a material upgrade with a maximum additional charge to the Enrollee of $75 per unit. Name brand, laboratory processed or in-office processed crowns/pontics produced through specialized technique or materials are material upgrades. The Contract Dentist may charge an additional fee not to exceed $325 in addition to the listed Cost Share. Refer to Schedule B for Limitations and Exclusions for additional information. If services for a listed procedure are performed by the assigned Contract Dentist, the Enrollee pays the specified Cost Share. Listed procedures which require a Dentist to provide Specialist Services, and are referred by the assigned Contract Dentist, must be authorized in writing by the plan. The Enrollee pays the Cost Share specified for such services. Procedures not listed above are not covered, however, may be available at the Contract Dentist’s “filed fees.” “Filed fees” means the Contract Dentist’s fees on file with Delta Dental. Questions regarding these fees should be directed to the Customer Service department at 800-589-4618. Optional is defined as any alternative procedure presented by the Contract Dentist that satisfies the same dental need as a covered procedure, is chosen by the Enrollee and is subject to the limitations and exclusions of this Amendment. The applicable charge to the Enrollee is the difference between the Contract Dentist’s usual and customary fee for the Optional procedure and the usual and customary fee for the covered procedure, plus any applicable Cost Share for the covered procedure.


SCHEDULE B - Limitations and Exclusions of Benefits

Limitations of Benefits for Pediatric Enrollees 1. Diagnostic and Preventive Benefits are limited as follows:

a) Bitewing radiographic images in conjunction with periodic examinations are limited to one (1) series of four (4) films in any six (6) consecutive month period. Isolated bitewing or periapical radiograph images are allowed on an emergency or episodic basis.

b) Full mouth radiographic images in conjunction with periodic examinations are limited to once every twenty-four (24) consecutive months.

c) Panoramic radiographic images are limited to once every twenty-four (24) consecutive months.

d) Caries risk assessment and documentation is limited to Enrollees age 3 to 18; limited to one (1) per thirty-six (36)-month period when performed by same Contract Dentist or office.

e) Prophylaxis services (D1110, D1120) (cleanings) are limited to two (2) in a twelve (12)-month period.

f) Topical applications of fluoride are limited to two (2) in a twelve (12) month period.

g) Dental sealant treatments are limited to permanent first and second molars only. The teeth must be caries free with no restorations on the mesial, distal or occlusal surfaces.

2. Restoration Benefits are limited to the following:

a) For the treatment of caries, if the tooth can be restored with amalgam, composite resin, acrylic, synthetic or plastic restorations, any other restoration such as a crown or jacket is considered optional.

b) Composite resin or acrylic restorations in posterior teeth are optional.

c) Replacement of a restoration is covered only when it is defective, as evidenced by conditions such as recurrent caries or fracture, and replacement is dentally necessary.

3. Endodontic Benefits are limited as follows:

Root canal therapy, including culture canal, is limited as follows: a) Re-treatment of root canals is a covered benefit only if clinical or radiographic signs of abscess formation are

present and/or the patient is experiencing symptoms.

b) Removal or re-treatment of silver points, overfills, underfills, incomplete fills or broken instruments lodged in a canal, in the absence of pathology, is not a covered benefit.

4. Periodontal Benefits are limited as follows:

a) Periodontal scaling and root planing and subgingival curettage are limited to five (5) quadrant treatments in any twelve (12) consecutive months.

5. Restorative and fixed prosthodontic onlay, crown and pontic. Benefits are limited as follows:

The crown benefit is limited as follows:

a) Replacement of each unit is limited to once every thirty-six (36) consecutive months, except when the crown is no longer functional as determined by the dental plan.

b) Only acrylic crowns and stainless steel crowns are a benefit for children under twelve (12) years of age. If other types of crowns are chosen as an optional benefit for children under twelve (12) years of age, the covered dental


benefit level will be that of an acrylic crown.

c) Crowns will be covered only if there is not enough retentive quality left in the tooth to hold a filling. For example, if the buccal or lingual walls are either fractured or decayed to the extent that they will not hold a filling.

d) Veneers posterior to the second bicuspid are considered optional. An allowance will be made for a cast full crown.

e) Porcelain/ceramic crowns and pontics on molars are considered a material upgrade with a maximum additional charge to the Enrollee of $150 per unit. For a covered porcelain-fused-to-metal crown or pontic, a porcelain margin is considered a material upgrade with a maximum additional charge to the Enrollee of $75 per unit.

The fixed bridge benefit is limited as follows:

a) Fixed bridges will be used only when a partial cannot satisfactorily restore the case. If fixed bridges are used when a partial could satisfactorily restore the case, it is considered optional treatment.

b) A fixed bridge is covered when it is necessary to replace a missing permanent anterior tooth in a person sixteen (16) years of age or older and the patient's oral health and general dental condition permits. For children under the age of sixteen (16), it is considered optional dental treatment. If performed on an Enrollee under the age of sixteen (16), the Enrollee must pay the difference in cost between the fixed bridge and a space maintainer.

c) Fixed bridges used to replace missing posterior teeth are considered optional when the abutment teeth are dentally sound and would be crowned only for the purpose of supporting a pontic.

d) Fixed bridges are optional when provided in connection with a partial denture on the same arch.

e) Replacement of an existing fixed bridge is covered only when it cannot be made satisfactory by repair.

f) The plan allows up to five (5) units of crown or bridgework per arch. Upon the sixth unit, the treatment is considered full mouth reconstruction, which is optional treatment.

g) Porcelain/ceramic fixed bridge retainers on molars are considered a material upgrade with a maximum

additional charge to the Enrollee of $150 per unit.

6. Removable Prosthetic Benefits are limited as follows: a) Partial dentures will not be replaced within thirty-six (36) consecutive months unless:

1) It is necessary due to natural tooth loss where the addition or replacement of teeth to the existing partial is not feasible; or

2) The denture is unsatisfactory and cannot be made satisfactory.

b) The covered dental benefit for partial dentures will be limited to the charges for a cast chrome or acrylic denture if this would satisfactorily restore an arch. If a more elaborate or precision appliance is chosen by the Enrollee and the Contract Dentist, and is not necessary to satisfactorily restore an arch, the Enrollee will be responsible for all additional charges.

c) A removable partial denture is considered an adequate restoration of a case when teeth are missing on both sides of the dental arch. Other treatments of such cases are considered optional.

d) Full upper and/or lower dentures are not to be replaced within thirty-six (36) consecutive months unless the existing denture is unsatisfactory and cannot be made satisfactory by reline or repair.

e) The covered dental benefit for complete dentures will be limited to the benefit level for a standard procedure. If a more personalized or specialized treatment is chosen by the patient and the dentist, the patient will be responsible for all additional charges.

f) Office or laboratory relines or rebases are limited to one (1) per arch in any twelve (12) consecutive months.

g) Tissue conditioning is limited to two (2) per denture.


h) Implants are considered an optional benefit.

i) Stayplates are a benefit only when used as anterior space maintainers for children.

7. Oral surgery limitation: a) The surgical removal of impacted teeth is a covered benefit only when evidence of pathology exists.

8. Other Benefits are limited as follows:

a) Oral sedatives are limited to those dispensed in a dental office by a practitioner acting within the scope of their licensure.

b) Nitrous oxide is limited to when it is dispensed in a dental office by a practitioner acting within the scope of their licensure.

c) A broken appointment charge will be applied in a fair and reasonable manner and will not apply in exigent circumstances where advance notice of cancellation was not reasonably possible.

9. Name brand, laboratory processed or in-office processed crowns/pontics produced through specialized technique or materials are material upgrades. Contract Dentists may offer services that utilize brand or trade names at an additional fee. The Enrollee must be offered the plan benefits of a high quality laboratory processed crown/ that may include: porcelain/ceramic; porcelain with base, noble or high-noble metal. If the Enrollee chooses the alternative of a material upgrade (name brand laboratory processed or in-office processed crowns produced through specialized technique or materials, including but not limited to: Captek, Procera, Lava, Empress and Cerec) the Contract Dentist may charge an additional fee not to exceed $325.00 in addition to the listed Cost Share. Contact the Customer Service department at 800-589-4618 if you have questions regarding the additional fee or name brand services.

Exclusions of Benefits for Pediatric Enrollees

The following dental services are excluded under the plan: 1. Services which, in the opinion of the Contract Dentist, are not necessary to the Enrollee’s dental health. 2. Procedures, appliances or restorations to correct congenital or developmental malformations are not covered Benefits

unless specifically listed under Schedule A, Description of Benefits and Cost Share for Pediatric Benefits. 3. Cosmetic dental care. 4. General anesthesia or intravenous/conscious sedation, unless specifically listed as a benefit or is given by a DeltaCare

USA Contract Dentist for covered oral surgery. 5. Experimental or investigational procedures. 6. Dental conditions arising out of and due to an Enrollee’s employment for which Worker's Compensation or an

Employer's Liability Law is payable. The participating dental plan shall provide the services at the time of need and the Enrollee shall cooperate to ensure that the participating dental plan is reimbursed for such Benefits.

7. Services which were provided without cost to the Enrollee by the State government or an agency thereof, or any

municipality, county or other subdivisions. 8. All related fees for admission, use, or stays in a hospital, outpatient surgery center, extended care facility, or other similar

care facility. 9. Major surgery for fractures and dislocations. 10. Loss or theft of dentures, fixed partial dentures (bridgework) or other appliances. 11. Dental expenses incurred in connection with any dental procedures started after termination of coverage or prior to the


date the Enrollee became eligible for such services. 12. Any service that is not specifically listed as a covered Benefit under Schedule A, Description of Benefits and Cost Share

for Pediatric Benefits. 13. Malignancies. 14. Dispensing of drugs not normally supplied in a dental office. 15. Additional treatment costs incurred because a dental procedure is unable to be performed in the Contract Dentist’s office

due to the general health and physical limitations of the Enrollee. 16. The cost of precious metals used in any form of dental Benefits. 17. The surgical removal of implants. 18. Services of a pedodontist/pediatric dentist for an Enrollee, except when the Enrollee is unable to be treated by his or her

primary care Contract Dentist, or treatment by a pedodontist/pediatric dentist is medically necessary. 19. Services which are eligible for reimbursement by insurance or covered under any other insurance, health care service

plan or dental plan. The participating dental plan shall provide the services at the time of need and the Enrollee shall cooperate to ensure that the participating dental plan is reimbursed for such Benefits.

20. Consultations or other diagnostic services for non-covered benefits. Medically Necessary Orthodontic for Pediatric Enrollees 1. Coverage for comprehensive orthodontic treatment requires acceptable documentation of a handicapping

malocclusion as evidence by a minimum score of 26 points on the Handicapping Labio-Lingual Deviation (HLD) Index California Modification Score Sheet Form and pre-treatment diagnostic casts. Comprehensive orthodontic treatment:

a) is limited to Enrollees who are between 13 to 18 years of age with a permanent dentition without a cleft palate or craniofacial anomaly; but

b) may start at birth for patients with a cleft palate or craniofacial anomaly. 2. Removable appliance therapy (D8210) or fixed appliance therapy (D8220) is limited to Enrollee between 6 to 12

years of age, once in a lifetime, to treat thumb sucking and/or tongue thrust.

3. The benefit for a pre-orthodontic treatment visit (D8660) includes needed oral/facial photographic images (D0350). Neither the Enrollee nor the plan may be charged for D0350 in conjunction with a pre-orthodontic treatment visit.

4. The number of covered periodic orthodontic treatment visits and length of covered active orthodontics is limited to a maximum of up to:

a) Handicapping malocclusion - Eight (8) quarterly visits;

b) Cleft palate or craniofacial anomaly - Six (6) quarterly visits for treatment of primary dentition;

c) Cleft palate or craniofacial anomaly - Eight (8) quarterly visits for treatment of mixed dentition; or

d) Cleft palate or craniofacial anomaly - Ten (10) quarterly visits for treatment of permanent dentition.

e) Facial growth management – Four (4) quarterly visits for treatment of primary dentition;

f) Facial growth management – Five (5) quarterly visits for treatment of mixed dentition;


g) Facial growth management - Eight (8) quarterly visits for treatment permanent dentition.

5. Orthodontic retention (D8680) is a separate benefit after the completion of covered comprehensive orthodontic

treatment which:

a) Includes removal of appliances and the construction and place of retainer(s); and

b) is limited to Enrollees up to age 19 and to one per arch after the completion of each phase of active treatment for retention of permanent dentition unless treatment was for a cleft palate or a craniofacial anomaly.

6. Cost Share is payable to the Contract Orthodontist who initiates banding in a course of prior authorized orthodontic

treatment. If, after banding has been initiated, the Enrollee changes to another Contract Orthodontist to continue orthodontic treatment, the Enrollee: a. will not be entitled to a refund of any amounts previously paid, and

b. will be responsible for all payments, up to and including the full Cost Share, that are required by the new Contract Orthodontist for completion of the orthodontic treatment.

7. Should an Enrollee’s coverage be canceled or terminated for any reason, and at the time of cancellation or

termination be receiving any orthodontic treatment, the Enrollee will be solely responsible for payment for treatment provided after cancellation or termination, except:

If an Enrollee is receiving ongoing orthodontic treatment at the time of termination, Delta Dental will continue to

provide orthodontic Benefits for:

a. For 60 days if the Enrollee is making monthly payments to the Contract Orthodontist; or

b. Until the later of 60 days after the date coverage terminates or the end of the quarter in progress, if the Enrollee is making quarterly payments to the Contract Orthodontist.

At the end of 60 days (or at the end of the Quarter), the Enrollee’s obligation shall be based on the Contract

Orthodontist’s usual fee at the beginning of treatment. The Contract Orthodontist will prorate the amount over the number of months to completion of the treatment. The Enrollee will make payments based on an arrangement with the Contract Orthodontist.


SCHEDULE C - Information Concerning Benefits Under The DeltaCare USA Program THIS MATRIX IS INTENDED TO BE USED TO COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THIS AMENDMENT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF PROGRAM BENEFITS AND LIMITATIONS.

(A) Deductibles None (B) Lifetime Maximums None (C) Out-of-Pocket Maximum Covered pediatric dental services apply to the out-of-pocket maximum in your Membership

Agreement and Evidence of Coverage. See your Health Plan Membership Agreement and Evidence of Coverage for information about your out-of-pocket maximum.

(D) Professional Services An Enrollee may be required to pay a Cost Share amount for each procedure as shown in the Description of Benefits and Cost Share, subject to the limitations and exclusions of the Program.

Cost Share ranges by category of service. Examples are as follows: Diagnostic Services No Cost Preventive Services No Cost Restorative Services No Cost Endodontic Services $ 40.00 - $ 350.00 Periodontic Services No Cost - $ 350.00 Prosthodontic Services, Removable $ 45.00 - $ 350.00 Prosthodontic Services, Fixed $ 80.00 - $ 350.00 Oral and Maxillofacial Surgery $ 65.00 - $ 350.00 Orthodontic Services (medically necessary only) No Cost - $1,000.00 Adjunctive General Services No Cost - $ 225.00

NOTE: Some services may not be covered. Certain services may be covered only if provided by specified Dentists, or may be subject to an additional charge.

Limitations apply to the frequency with which some services may be obtained. For example: cleanings are limited to two in a 12 month period; Replacement of a crown is limited to once every thirty-six (36) consecutive months for Pediatric Enrollees.

(D) Outpatient Services Not Covered (E) Hospitalization Services Not Covered (F) Emergency Dental Coverage Benefits for Emergency Pediatric Dental Services by an Out-of-Network Dentist are limited

to necessary care to stabilize the Enrollee’s condition and/or provide palliative relief. (G) Ambulance Services Not Covered (H) Prescription Drug Services Not Covered

(I) Durable Medical Equipment Not Covered

(J) Mental Health Services Not Covered (K) Chemical Dependency Services

Not Covered

(L) Home Health Services Not Covered (M) Other Not Covered

Each individual procedure within each category listed above, and that is covered under the Program, has a specific Cost Share that is shown in the Description of Benefits and Cost Share for Pediatric Benefits in this Amendment.


If you have any questions or need additional information, call or write:

Toll Free 800-589-4618

Delta Dental Insurance Company P.O. Box 1803 Alpharetta, GA 30023

IMPORTANT: Can you read this document? If not, we can have somebody help you read it. For free help, please call Delta Dental at 1-800-589-4618. You may also be able to receive this document in Spanish or Chinese. IMPORTANTE: ¿Puede leer este documento? Si no, podemos ayudarle. Para obtener ayuda gratis, llame a Delta Dental al 1-800-589-4618. También puede recibir este documento en español o chino. 重要通知：您能讀這份文件嗎？如有問題，我們可請他人

協助您。如需免費協助，請電Delta Dental 1-800-589-4618 您也能取得這份文件的西班牙文或中文譯本。
